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Health Matters Gibraltar Health Authority Annual Report 2005 Health Matters Gibraltar Health Authority Annual Report 2005 Credits PUBLIC HEALTH SECTION Dr. Vijay Kumar, Director of Public Health (lead) Miss M. Sene, Cancer Registry officer Mr. J. Easter, Health Promotion Officer HEALTH CARE SECTION Dr. David McCutcheon, Chief Executive (lead) Contents Public Health in 2003 Vital Statistics Immunisations Life expectancy and mortality Health Promotion Infectious Diseases What is Bioterrorism? Response to Bioterrorism SARS 8 8 8 9 10 12 14 14 15 Health Care in 2003 Gibraltar Healthcare Development Programme Obstetrics and Gynaecology General Medicine and Specialties Paediatrics Anaesthesia and Intensive Care The late Dr. Andrew Correa - Obituary Laboratory services Speech assessment and therapy Operating Theatre The New Hospital Eye Care ENT Services Information Technology Palliative Care Clinical Psychology Mental Welfare Services Physiotherapy Occupational Therapy Nutrition and Dietetics 16 16 16 17 17 18 18 19 19 20 20 21 21 21 22 22 22 23 23 23 Dr. P. J. Nerney, Primary Care Co-ordinator Dr. S. Higgs, Consultant paediatrician Mr. M. Haroon, Consultant ophthalmologist Mrs. C. Vinent, Senior Physiotherapist Mr. A. Wink, Senior Occupational therapist Ms. M. McLeod, Senior Dietitian Mr. A. Montero, Laboratory Manager Mrs. C. Macias, Sponsored Patients Officer Mrs. G. Phillips, Head Pharmacist Mr. E. Lima, Director of Finance and Information Technology Mrs. E. Cervan, Medical Records Manager PRODUCTION Mr. S. Perera (graphic design & photography) Mr. S. Escudero (photography) Miss M. Sene (administration and proof reading) Public Health 2004 Minister’s Foreword The Hon. Ernest Britto, Minister for Health The period covered by this report culminated with the most exciting and significant improvement to our Health Services in many decades when we inaugurated our new St. Bernard’s Hospital at Europort. This came as a result of many months of meticulous planning and hard work by GHA Staff throughout the preparations for the main move on 12th February 2005. Some departments started to move into the new building during late 2004. The opening of our new St. Bernard’s Hospital required a capital investment in excess of £55,000,000, including some £20,000,000 of new equipment. The success story of the New Hospital is there for all to see and from the very first day it started to attract favourable comments, not only from patients and their families, but also from visiting health professionals who compare it favourably with private hospitals of the highest standards in their own countries. Gibraltar is indebted to all those who in any way either directly or indirectly helped GHA in the successful migration of all its patients in St Bernard’s Hospital from its old location in the upper town to its new environment in the Europort area. The migration went quite smoothly and all patients and essential equipment were moved within a 5 hour period. Without doubt, this would not have been possible except for the understanding and co-operation of those who suffered the inconvenience of drastically reduced parking in the vicinity of both hospitals as well as on the routes between them. Also noteworthy was the co-operation of the general public in avoiding the use of their vehicles during the migration period. This eased the circulation of traffic and made it so much easier for the vehicles carrying patients to move between the two hospitals. All members of the GHA Staff co-operated magnificently by their full attendance, the long hours worked and by carrying out the transfer so efficiently and effectively. Last but not least, Gibraltar’s gratitude goes to the patients and their families for their forebearance and patience during the move and in the subsequent period of adjustment after arrival at the new hospital. Their co-operation was fantastic and they helped to make the job of all those persons involved with the move very much easier. It would be foolish of me to pretend that as a result of the new hospital everything is now perfect in our Health Service, that there is nothing more to do to continue to improve it, or that regrettable patient incidents and experiences will not occur from time to time. But the same is true of even the best medical facilities in the world. To ensure that we learn from mistakes so that they do not reoccur, in September 2004 we opened the Health Services to greater scrutiny. Not only is the GHA’s own internal complaints procedure more open, timely and transparent, but it now includes an external examination by an Independent Panel from outside the GHA with very great powers of investigation. Of course, the opening of the new St. Bernard’s Hospital has not just been the inauguration of a new building, impressive as it is. The wards are divided into spacious and comfortable rooms with one, two, three or four beds in each and most rooms have their own bathroom. A total of 212 beds are available, about 40 more than in the old hospital, and each bed is being provided with its own television and radio facility. There are three Operating Theatres, as opposed to only one in the old hospital, as well as day-surgery facilities. There is a modern and enlarged Accident & Emergency Department, a dignified and spacious Mortuary, an Endoscopy Suite and a Staff and Visitors Canteen. But as I said, the new building is not the whole story. More Consultants will soon be recruited and new medical services, never provided before in Gibraltar, will soon be available here. The forthcoming arrival of a new Consultant General Surgeon will help with the launch of the new concept of day surgery, as well as with the introduction of new techniques such as ‘keyhole surgery’. Improvements will also be carried out in the coming months to our system of patients health records, to our procurement methods and to our IT and Communications systems. Continuing to look through to the future, we will be seeking to carry out further improvement to systems and practices at the Primary Care Centre in order to provide a more patient friendly service. We are also in the initial stages of preparation to carry out a review and modernisation of mental health legislation and facilities at the KGV Psychiatric Hospital. Without any doubt the major developments expected in the coming months will be the inauguration, for the first time ever in Gibraltar, of a Dialysis Clinic, of a CT Scan and a Mammography Service. This is the measure of our commitment to our health service and of the huge transformation that is being brought about. We shall continue to bring about improvements where they are needed and possible because the health of our families is the most important thing for us and we will continue to deal with our health service on that same basis. Vital Statistics Population According to the Government Statistical Office, the final results of the national Census 2001 published this year showed the resident population of Gibraltar to be 27,495, representing a growth of 3% from the previous census in 1991. These finally published figures differ only very marginally from the provisional figures originally published and therefore the analysis presented in the public health report for the year 2002 remains largely valid. Births The number of babies born in Gibraltar rose dramatically in 2004 to 421, when compared to the relatively constant numbers in previous years (around 360). Of these, 223 were females and 198 were males. The proportion of these births attributable to the resident population was 91.2%, that of the Forces population accounting for the rest. The birth rate in the resident population rose sharply this year to 14.0% reversing the downward trend in local birth rates since 1992. The birth rate in the Forces population is estimated to be 23.0, also a significant rise. The number of births to teenage mothers remained constant this year at 23, but this year for the first time, a birth occurred in a mother as young as 14. There was also one birth to a 15-year-old mother. The overall number of teenage mothers each year has hardly changed in recent years and continues to be a matter for concern. There were no teenage pregnancies this year in the Forces population. At the other extreme, there was a significant rise in births to mothers aged 40 years or older – this year there were 16 births (3.8%) in this age group as against 5 (1.5%) in 2003 and 8 (2.2%) in 2002. The age of the oldest mother was 51, while the oldest mother in 2003 was 43. Life expectancy Gibraltar enjoys a good Life expectancy in keeping with the standards for western societies and the actuarial tables from the Census 2001 show that a baby born in 2001 could expect to live up to 78.5 years (if male) or 83.3 years (if female). The magnitude of this change is dramatic considering that life expectancies were a full ten years lower, barely 30 years ago (1970). The mean age of death in the resident population was 77.3 years (males) and 80.6 years (females), slightly higher than in previous years. Deaths During 2004, 111 females and 110 males died, giving a total of 221 deaths in the resident population, a crude death rate of 8.0, again roughly similar to previous years. A further fifteen deaths of non-residents were also registered in Gibraltar. There were no stillbirths or early childhood deaths this year. Once again, the differences in gender patterns for the age of death were pronounced, but less striking to previous years. This year, the pattern for both men and women showed similar numbers of deaths until the mid 60s, after which the death rate for men rises sharply to peak at around 80, falling gradually thereafter, while for women, the peak occurs a few years later, in the mid 80s. Only 13 men reached the 90s, the oldest dying at 96. In contrast 26 women reached 90, three women reached a 100 and one woman survived to 104. Heart Disease - this year with 49 deaths (22%) - used to be the most common cause of death but this year has yielded its supremacy to Cancer, with 50 deaths (23%). This phenomenon is not unexpected, as people are living healthier lives through to older ages when cancer is more common. However, the actual numbers of deaths from both heart disease and cancer were the lowest this year for the last seven years. The types of cancer causing deaths have changed this year. Prostate cancer was responsible for the most deaths, followed by cancer of the pancreas. Although lung cancer was the cause of only three deaths this year, it still kills young – it was responsible for the second-youngest person to die of cancer, a woman of just 34. Breast Cancer was responsible for 4 deaths this year. As in previous years, 16% of the deaths occurred at home. Again as in previous years, 25 persons (11%) who died had diabetes recorded as a contributory factor. Details of the main causes of death and comparisons to previous years can be found in the tables. ‘Premature’ mortality Cancer As in past years, a review of all deaths under 65 was made. This is usually taken as an indication While counting deaths is useful as an outcome Registry. Such instances are very rare and very few indicator for the quality of care and services, it cases should be lost. is not a good reflector of causation, for which Radiological cancers are the most significant of the incidence data would be more useful. The three groups, not only in terms of numbers, but also Gibraltar Cancer Registry was set up in 1999 in the wider prevalence of some of these cancers. to collect statistics on each case of cancer as These are cancers which are primarily diagnosed it becomes incident. Subsequently, incident by xray and not by pathology – examples are lung cancers for the year 1998 were added but further cancer, some bone cancers, pancreatic cancer, etc. addition of retrospective data will not take place These constitute a significant number and the landmark. However, this year the position appears to be more even. Cancer continues to engender public anxiety despite the fact that death rates from cancer in Gibraltar are still lower than the UK or Spain. This is because of many reasons, not all medical. Research evidence in Spain showing high cancer death rates in Andalucia, the presence of nearby industries such as the Refinery in Algeciras and a general fear of radiation are some reasons. Also, in a small insular community, as every event eventually touches everyone, events that arouse fear such as cancer, even if rare, are always remembered and the incidence will appear to be magnified. as it is not possible to assure data quality. The potential for data loss is real. The matter has been Cancer Registry continues to register new cases The cause of death in people under 65 is changing. In the past, deaths from heart disease in Cancer and the Environment pursued since the early days of the Cancer Registry, of cancer. people under 65 had frequently reflected patterns similar to the other age groups, but this year, but the lack of a radiology information system Grossly polluted environments can contain harmful agents that contribute to cancer, but the actual contribution of the environment to cancer is often overstated. The influences of several other factors in human health - genetic, lifestyle, dietary and other - often dwarf that of the environment, particularly in communities where air, water, food and soil are regulated. The Cancer Registry draws its data primarily from meant that such data was practically impossible to the reports of pathology department as almost all retrieve after the event. Efforts are under way to use diagnoses of cancer are made there. Protocols are notification procedures in the new hospital, with its now established for the notification, collection more sophisticated radiology information system. and quality control of the data originating from It is intended to carry out an audit of data quality this source and work well. There are however in the following year. A summary of the cancer some cancers that may fail to be notified through notifications from 1998 to 2004 as stored in the these means and these fall into the following Registry is presented in the tables. of “premature” mortality, assuming that a key health goal for all Gibraltar residents is to achieve survival to at least 65 years, which is still 10 years below average life expectancy. Of the 221 people who died this year, only 21 (9.5%) were under 65 years, a fall from the usual proportion of around 18%, which is a very encouraging development. In previous years the gender contrast has been striking, with premature mortality being a much bigger problem with men, than with women. For example, last year, only 11% of women died before their 65th birthday, whereas 23% of men (nearly a quarter) failed to reach this the fall in overall heart disease mortality is matched by an even greater drop in the under 65s – only two people died of heart disease. However, more than half of these people died of cancer (52%) but it was not possible to identify a specific type of cancer as being more contributory. The resident population of Gibraltar is 27,495, representing a growth of 3% from the previous census in 1991 The following are the chief influences in the Gibraltar environment. • By far the most strongly proven cause of environmental pollution is tobacco smoke, which directly and intensely pollutes the inhaled air of both the smoker and those exposed passively. The attributable risk from this one factor dwarfs all other factors, for those who are affected. • The biggest cause of general air pollution in Gibraltar is traffic. Peak hours and frontier queues result in large numbers of stagnant vehicles burning fuel inefficiently, sharply raising levels of hazardous gases and particles in the air. There could be number of localised areas of air pollution, the most obvious example being the Dockyard, with low-level smoke from generators and aerosolised industrial paint. • Other contributors are relatively insignificant. The Refinery is often blamed, but the dilutional effect of wind forces and distance reduce this risk considerably, provided the plant as a whole is adequately regulated. Drinking water pollution is not a problem because of desalinated production. Bathing water in the beaches is more affected by sewage pollution, but this is intermittent. Trends in mortality It is difficult to make a statement about trends in mortality as the numbers fluctuate fairly widely, albeit within a narrow margin. It is safe to say that the total number of deaths this year (221) is the second lowest in the past seven years. However, when the causes of death are examined for trends over the past seven years (1998 to 2004), it is striking that the number of deaths from Heart disease show a clear downward trend while the levels of other causes remain more or less the same. This is encouraging and although it is too early to judge the factors behind this trend, it is at least likely that advances in surgical and medical treatments, together with the messages about smoking reduction, weight reduction and healthy lifestyles may be having an impact. Cancer Registration There is very little food manufacturing in Gibraltar and environmental food pollution issues are few. Imported problems (such as mercury pollution of swordfish) are addressed as they arise. Soil pollution has not been greatly investigated, but a recent geological study by a local student showed some heavy metal residues from the military past but not to a great concern. The conclusion is that apart from tobacco smoke, there is at present no identifiable and serious environmental carcinogenic threat operating significantly at a population level. Analysis of the cancer registry database may yield further hypotheses. categories: Cancers investigated and diagnosed by overseas pathology departments (e.g. Royal Marsden Hospital) are not always notified to the St Bernard’s Hospital Pathology department and efforts “Eating fruits and vegetables every day prevents cancer” are being made to improve coverage. Cancers diagnosed privately (in Spain or elsewhere) may only reach the Registry if the patient returns to the public sector and a copy of the pathology report is forwarded to the laboratory. Inoperable cancers (eg. some head and neck cancers, vascular sarcomas, etc.) are sometimes not investigated pathologically, but this is rare and when this happens, there are now agreed notification procedures with the general and ENT surgeons to notify such cases to the Infectious Diseases Laboratory confirmed notifiable infections Again this year, there was a small rise in infectious disease notifications (199) compared to the previous year (184), but still below the large numbers regularly seen before 2001 (over 230). There was a sharp fall in the number of cases of food-borne infections such as Salmonella and Campylobacter, which again accounted for most of the fall in notifications. There were 90 cases of Salmonella as opposed to 129 last year, and 32 cases of Campylobacter infections this year as opposed to 24 last year. The continued reduction in Campylobacter infections seems to suggest that the standards of public hygiene may have improved. There was a small outbreak of salmonella infection among some long stay residents of KGV hospital. The cause of this was identified to be delays between the cooking and serving of the food to the residents. Measures were taken to minimise this delay and it is hoped that the situation will improve even more under the new catering facility set up by the Authority. There were no cases of meningococcal infection during 2004. Multi-Resistant Staphylococcus Aureus (MRSA) During 2004, 33 cases of infection due to MRSA (multi-resistant staphylococcus aureus, an organism resistant to most antibiotics) were reported. This was an unusually large number and warranted further study. An audit was carried out of all MRSA infections ever recorded. It was found that between 1994 (when the first case of MRSA was isolated in St. Bernard’s Hospital) and 1998, MRSA isolations were relatively rare, around 2 to 3 per year. Between 1999 and 2003, the incidence increased to around 13-15 infections per year. This period coincided with a huge upsurge of MRSA in several countries of the world (including UK and Spain) and nearly half of all cases could be clearly identified as having been imported by patients returning from overseas hospitals. Despite stringent measures adopted, a certain number of homegrown and hospital acquired MRSA infections also began to make an appearance. It is also possible that the increased interest and attention to MRSA led to more cases being investigated and identified. Against this background, the finding of 33 cases in 2004 was still unprecedented. On closer analysis, it emerged that the number of cases acquired from abroad was falling and was the lowest since 2001. Thus imports could not be blamed for the rise, but instead increases were observed throughout every other category. There were also some freak occurrences, such as an unrelated cluster of long stay residents, two septicaemias and an unexplained large group of persons with intrinsic infection, all of which may have inflated the figures without providing a cohesive explanation. Thus, the audit did not pinpoint any single factor responsible for the unusually large number of MRSA infections in 2004. It is of course possible that this was an aberrant year, the figures being no more than a statistical oddity. Only future years will tell whether this rise will dissipate, or be sustained, indicating a greater endemicity of MRSA in line with the UK and elsewhere. Other infections Following the admission of a patient with UK acquired scabies infection, several ward staff who reported with itch symptoms were reviewed by the specialist dermatologist but no scabies was found. There was a rise in chlamydia isolations, from less than 3 a year in previous years to 8 this year. This is more probably an indication of greater awareness among health professionals rather than any abrupt increase in incidence. Immunisation Routine immunisation programmes continued to be carried out during 2004 as per schedule. The annual winter Influenza vaccine campaign also continued this year. However, the key event of the year in immunisation was the introduction of the Five-in-One vaccine. The Five-in-One vaccine (or more correctly known as DTaP/ IPV/Hib vaccine) is a new vaccine that replaces three vaccines that are normally given to all children separately - the old Triple vaccine, the Polio vaccine and the Hib vaccine. The new vaccine had been used in the routine childhood programme in Canada since 1997 and was introduced in the UK in early 2004. It produces very effective immunity to five serious diseases of babies and small children : Diphtheria, Tetanus, Pertussis (also called Whooping Cough), Haemophilus Influenzae B infection (also called Hib) and Polio. When compared to the existing vaccines, the new Five-In-One vaccine offered four major areas of benefit: • It uses inactivated (killed) Polio virus, as opposed to the live virus in the old vaccine, thus abolishing the slight risk of causing vaccine-associated paralytic disease. a model lung, which attempted to illustrate the damage smoking causes to our body. Materials purchased ran out quickly and more should have been purchased to cover St. Bernard’s hospital and other departments such as the youth and social services. The late arrival of campaign resources from the UK presented difficulties for the timely dissemination of posters, stickers, banners and leaflets to schools and other public places. The No Smoking Day campaign’s effectiveness at population level depends on achieving wide reach, particularly among individuals most likely to respond positively. The public response to the campaign was reasonably good. A few individuals approached the table for information on how to quit smoking. The campaign must continue to keep awareness levels high in order to ensure that smokers have the opportunity to respond. Radio Gibraltar reported the event in an early morning piece preceded by a series of talks on Healthfile. GBC TV covered the event on the day and screened the interview on Newswatch. A series of articles were published in the Gibraltar Chronicle before and during the campaign, covering such areas as smoking in young people, smoking in the workplace and passive smoking. It was not surprising that, as on so many past occasions, the majority of people who visited the displays wanted to know when smoking cessation clinics would be set up. The development of smoking cessation services is essential and pressing. • It uses acellular pertussis vaccine instead of whole-cell pertussis vaccine, thus reducing the risk of neurological side effects. • It has no Thiomersal (mercury) in the vaccine, thus reducing allergic skin reactions • The combining of the vaccines means fewer injections and clinic visits for the baby. The switch-over went smoothly and without incident. Sun Awareness Campaign, summer 2004 Gibraltar’s sixth Sun Safety Campaign took place on 12th June 2004 with the now regular beach visits. Some hot weather ensured that the campaign was well timed. Bioterrorism Bioterrorism continues to remain a matter of importance in the wider political scene and the local preparedness in the face of the smallpox threat was described in last year’s report. A key deficiency identified was the lack of awareness and training on bioterrorism in health care professionals and in February 2004, the department organised a Seminar on Bioterrorism with the support of the Civil Contingency fund. It was inaugurated by the Minister, delivered by the foremost experts in the field from the UK and attended by a large number of local doctors and health care professionals. The resources included lectures, discussions, a simulation exercise, an inter-services workshop and study materials. Participants as well as faculty judged the Seminar to have been a great success. The health service responded to two Suspect Package Incidents during the summer, involving white dust falling out of letter packets. These were analysed by the hospital laboratory and revealed a white, gritty, crystalline, organo-chemical substance, which was proved not to contain anthrax. Although no harmful substance was found, circumstantial factors suggested a malicious intent and the matter was taken up by the Police. The Miss Gibraltar contestants’ help was again invaluable and they did tend to focus on promoting sun safe behaviour to the adolescents. Newall Holdings Ltd kindly sponsored the event supplying T-shirts for the campaigners with the message ‘Keep the sun off your back’ on the reverse to create a uniform look, bottles of sunscreens for use throughout the campaign and refreshments for the campaigners. A campaign bus and driver were hired. Articles were published in the Gibraltar Chronicle, Insight Magazine, and the Panorama. A radio piece was aired for the GBC Healthfile slot. The Health Promotion Leaflets ‘The Sun & you’ were re-printed for the campaign and distributed at the beaches. They were also distributed to all pharmacies, the post office, supermarkets and other public places such as bars. The successful A5 flyer Health Promotion As has been the case in recent years, the year 2004 continued to be a very active and busy one for the Health Promotion department. The delivery of the department’s campaigns, literature production, organisation of events and leading initiatives still continues to be shouldered by a single Health Promotion Officer, a situation that has become stretched. The multi-agency collaborative Health Promotion Group has continued to meet regularly throughout the year. The following is a summary of the campaigns, events and developments that have occurred in the field of health promotion during the year. No Smoking Day, March 2004 Wednesday 10th March 2004 was Gibraltar’s fifth consecutive No Smoking Day. The Day’s combination of highly visible public displays at the Primary Care Centre and media involvement intended to intensify and widen awareness, with the ultimate aim of fostering a supportive environment for smokers wanting to take steps towards quitting. ‘Be Sunwise’ featuring the character ‘Sunny’ and aimed at preparing the children to be ‘sun wise’ during the summer break was distributed to all schools and nurseries again this year. Posters were also printed and distributed to the above establishments. It however seemed that the public reaction to the campaign was not as positive as in previous years. It is possible that the campaign has become jaded with repetition and a different angle will be explored next summer. The ‘Be Sunwise’ campaign promotes high-factor protection Coronary Heart Disease Awareness Day 2004 The third Coronary Heart Disease Awareness Week took place on 8th - 12th November 2004 at the Primary Care Centre. Information was displayed as usual, aimed at both heart disease patients and well people, but in addition there were themed displays on ‘women and CHD’ and ‘men over the age of 40’. The Cardiac Nurse Specialist kindly monitored and managed the resources throughout the week. Banners carrying information on CHD in Gibraltar were hung around the foyer of the PCC (main area) and were very noticeable. The new leaflet ‘Looking after your heart’ produced by the Health Promotion Group specifically for the event was distributed within Primary Care. Articles on CHD were written and submitted in the Gibraltar Chronicle during CHD week. The Chronicle also provided the front-page headline “Gibraltar’s Biggest Killer Revealed”, which stimulated public interest. Insight Magazine also published an article. An interview was broadcast on GBC TV on the campaign and the importance of CHD awareness in Gibraltar. There was quite a lot of positive feedback from the public. Several health care professionals in Primary Care also expressed appreciation for the campaign in this important area. There were many different posters on display, a wide variety of leaflets and even 10 11 The GOOD Health Award scheme has been in operation now for two years. Coronary Heart Disease (CHD) is one of the biggest killers globally as well as locally and the prevalence of overweight and obesity is rising in the local community in adults and children. The Scheme is intended to encourage restaurateurs and caterers to promote healthy eating in the community. By taking part in the scheme and gaining the award, caterers can make a positive contribution towards safe dining and healthier living. Trying to motivate restaurateurs onto the scheme has not proved to be easy as there are many commercial disincentives. However, the work of the Tourist Board in promoting the award-winning restaurants is a valuable asset. The current Awardees are listed below: Gold Award Silver Award Bronze Award The Rock Hotel Airside Services Bunters Rooke Officers Mess (MoD) WO + Sgt’s Mess (MoD) Devils Tower Camp (MoD) Carpenters Arms Little Rock Café Kowloon Chinese Restaurant The Clipper Paradiso Chez Nous Just Desserts Café Boheme Bug Busting There is still a lot of public confusion on the proper approaches to address the head lice problem with calls to bring back the ‘nit nurse’. This is a misunderstanding, as this old-fashioned resource, while being expensive has never really delivered the expected results. The best place to address the problem of lice infestation is the home, not the school or the doctor’s surgery. Regular parental attention and care is the only approach that will rid the child of head lice. With this in mind, the department organises Gibraltar’s Bug busting campaigns regularly scheduled for 1st February and 1st October every year. The purpose of these is to provide parents, schools and childcare establishments a unified and synchronised focus for lice disinfestation, thus reducing opportunities for re-infestation. Supportive leaflets on head louse infestation and its management were produced by the Health Promotion Group and distributed to the children by the education department. Additional posters were created and placed in the Primary Care Centre waiting rooms and in the schools. Professional advice to teachers and parents was also made available. The literature was updated this year to clarify the roles of professionals, to provide useful advice in managing difficult infestations and eradicate the harsh unnecessary practice of child exclusion. Health Promotion Group WebPage Perhaps the most exciting event in the Gibraltar Health Promotion Group’s calendar this year was the launch of its website, developed with the aim of providing an information service for the public as well as for health professionals. The site was developed with help and suggestions from a number of health professionals who focused on creating a site that would be an informative yet friendly resource bank. The website address is www.health.gov.gi The website has broadly been constructed around a main page describing the work of the Group, with information on contacts, listing of events and links to download leaflets. There are also sub-sites for parents and carers (focusing on positive parenting, with a useful section on nutrition of children), for teenagers (youth zone) and for younger children (with quizzes and fun stuff evolved around a health theme). The whole process of publishing the site, from the storyboard through construction to launch has involved a huge amount of work, including a detailed review of the literature and professional assistance from graphic and web designers. However, knowledge does not stand still and it is hoped that users will contribute to keeping the site updated and accurate. While such a resource can be very useful, care has been taken to point out that the website is not intended to act as a substitute for personal medical advice, but aims to provide generic information on a variety of health issues. Personal advice should always be sought from the appropriate health professionals. Bus stop posters One of the innovative approaches that the Health Promotion Group has introduced is the use of bus shelters to disseminate health promotion messages. The Claims Centre very kindly provide space at no cost and the Group has produced a number of posters on various topics, including: Sun Safety, Smoking and The GOOD Health Award Scheme, all of which were displayed at several points during the year and rotated. Posters under development include Promoting fruit and vegetables ( 5 a day), protection against STDs and HIV/AIDS awareness. Involvement with other agencies The Department, through the Health Promotion Officer, is also involved in collaborative work on promoting health with several local groups such as the Department of Education, the Sports Development Unit and the British Forces Health Promotion Group Press and Media Relations The Health Promotion Officer continues to contribute regularly to Radio Gibraltar’s “HealthFile” slot at monthly intervals. The purpose of these interviews is to raise awareness on a variety of health-related matters and to encourage individuals to adopt a healthier lifestyle. It is also used to publicise forthcoming campaigns. Health advertising on television (“infomercials”) has great potential but past experience has shown that commercial production is prohibitively expensive and amateur production is unreliable. Nevertheless the efforts continue. Radio infomercials are also an important medium for health promotion and requiring a lesser technical approach to the construction of the product, seem more attractive. Key issues to tackle would be smoking, obesity and sun awareness. To put things into perspective, it should be emphasised that although people find them repulsive, head lice are not really a medical problem, as they do not spread disease. Even the symptoms (such as itch) only arise because of the body’s intolerance of the parasite and does not occur in everyone. Better understanding can prevent a lot of unnecessary hype, anxiety and overreaction. 12 13 Mount Alvernia A PCC GP visits Mount Alvernia four times weekly for 3 hours at a time. Full emergency cover is provided at all times. Health Care in 2004 Home Help Pilot Scheme This has been a source of considerable help to many elderly people living at home without adequate family support. It is an important means of enabling elderly people to remain in the community rather than having to admit them to hospital. PCC Nurses Primary Care General Practitioners The GP complement has been held at 16 . Continuing Professional Development (CPD): • The process of in house performance Appraisal has begun with a visit and initial assessment of trained GP Assessors from the UK. All GHA GPs have been appraised and a suitably tailored programme of CPD developed. • There are continuing fortnightly CPD sessions for all PCC GPs. These are dedicated to practical general practice issues and case presentations. They are organised by the GP group. • Intercalated with these sessions are fortnightly Multi-disciplinary sessions of wide interest to all GHA medical, nursing and PAMs staff. These are held in the PCC on alternate Wednesday afternoons, are organised by Dr J Negrette and are well attended. • Five GPs have attended week long refresher courses in the U.K. • Hospital based Basic Life Support refresher courses are now organised for all PCC medical/nursing staff. We have continued to develop the concept of PCC clinic nurses working together in small groups providing support for small groups of GPs and their patients. Instead of spending time in the GP clinic helping the individual GP as required the nurses are based outside the clinic. They will have an increasing range of responsibilities some of which will be clinical e.g. triage, history taking, blood pressure and blood sugar monitoring. In this way we expect that the nurses role will become more pro-active, more responsible and more useful. The nurses will not simply be GP’s assistants but will also have a developing independent role. One Clinic Nurse is now in charge of cryotherapy sessions – previously a GP’s remit. She also assists in the visiting Dermatologists clinic which is now held in the PCC. The two Nurse Practitioners are now established and carrying out an absolutely invaluable task covering many aspects of what was previously considered a Doctor’s role. Operational Changes Emergency Team arrangements Demand continues to rise and the emergency Clinics of both GPs and Nurse Practitioners remain over-pressed. We are now running regular, Specialist GP supported, Dermatologists’ clinics in the PCC with notably reduced waiting times and greatly improved educational content. Some GP clinics times are now staggered allowing appointments over lunch time and ensuring a GP presence in the PCC at all times. Computerisation Electronic Appointment System In the past year we have developed a PCC IT Network well supported by Mr Heath Watson. This system has been operational since Summer 2003. It has been regularly updated and developed in response to circumstance and has certainly allowed us to offer a better service than with the old paper based system. Many more PCC staff now have basic Computer support. All of the PAMs departments, all Admin areas and most of the GPs have PCs. In all there are about 40 PC s in the PCC. These PCs are linked to the PCC server. It is now much easier than before to make an appointment by ‘phone’. However considering that 400 appointments on average are made daily at the PCC it is clear that it will never be possible to guarantee instant ‘phone’ access. There is a deluge of phone calls to the pcc between 8 and 10 am which creates problems at that time. We all now have access to the e British national formulary. The GPs have in house, amateur clinical database software and access to the central PCC appointment system. However, we still lack a networked professional clinical system and this is a major weakness in the PCC set up. It severely limits our ability to provide a high quality service. The failure to re-register patients has also prevented many positive developments. Each patient is now given a definite appointment time rather than a block booking time shared with other patients. Most GPs now offer 14 seven and a half minute appointment. Each GP in a normal clinic sees an average of 16 patients per session. 15 Report of the Paediatric Department 2004 Altogether 7010 children were seen at the Child Welfare Clinic, of which 583 were examined by the paediatrician, 971 assessed by the Health Visitirs, and 299 by Dr Vasallo (2 years assessments) The Paediatric Department continued to extend its service The Child Welfare Clinic Staff and School Health nurses provided an excellent and dedicated service throughout the year during 2004, both in hospital and in the community. Child Protection Hospital The Child Protection Team headed by the paediatrician comprises the child welfare staff, midwives, social workers, general practitioner, accident and emergency staff and the Director of Public Health. The team has met at intervals to discuss providing an intact system to identify and manage children at risk. The ‘at risk’ register is kept up to date and communication between the various disciplines is good. A protocol for management of the ‘at risk’ child (protection policy) is being drafted. There were 888 patients admitted to Rainbow Ward during the year of which. 447 were Medical, 79 Surgical, 238 dental, 44 orthopawedic, 90 ENT, 9 Gynaecology, 8 Plastic Surgery, 3 Opthalmology. In the General Outpatient Clinic 620 children were seen by Attention is being given to acquiring further child protection training to all staff involved. the Paediatrician. School / Department of Education escalated as a result of meeting the need for early or urgent The visits of Dr Philip Jardine, Paediatric Neurologist from Bristol at 6 monthly intervals ensures that all Special needs children are seen annually. These visits have been of immense help in identifying the complex diagnoses in these children and focusing specific treatment and management programmes. The paediatrician individually assesses the children on weekly visits to St Martins School in preparation for the neurologist’s visit. referral allowing children to be seen within 2 or 3 days of referral. Altogether 497 children were seen. The Allergy Clinic has become the busiest clinic of all. Children are investigated for their allergies by the Allergy The input from the special needs teachers, speech, occupational and physiotherapists working with these children is deeply appreciated. The centralisation of these services ensures a comprehensive service, which is second to none. Team, including skin testing and blood tests. The two lead nurses continue to contribute to the care with their expertise. incorporating individual counselling by Sr Mary Sene, Newborns regular checks and a visiting service by Dr Ahmed Massoud, The fruits of the distance-learning course in 2003 paid off in the form of better neonatal nursing care through the year of 2004. Paediatric Endocrinologist from Northwick Park, London. The use of insulin pumps is being investigated in line with modern trends. Sr Sene attended a workshop in this respect A number of sick newborns and preterm infants were managed in the unit, obviating transfer of the newborns to the Intensive Care Unit in Malaga. Throughout the year a total of newborns/premature infants were transferred to Malaga. Constant communication and sharing of knowledge occurs With the opening of the new hospital and in particular the Neonatal High Care Unit, more sick infants will be able to be managed locally. The new CPAP machine for noninvasive ventilation will enable infants with mild respiratory distress to be treated without transfer. between the consultant and the nursing staff mainly on an The nursing staff is to be congratulated on their fine record of care. informal basis. It is hoped that a formal continuing education Altogether 377 infants were born in the Unit. The caesarean section rate was 23%. There were no stillbirths or deaths. in London recently. Adolescent counselling has received priority in order to improve control in this difficult group. programme will be possible in 2005 when the consultant will have more time on the ward for teaching. Sr Sene and her staff are to be congratulated for their dedication, excellent standard of nursing and holistic approach to patient and parent care. Mothers were transferred to Malaga in premature labour and 1 was transferred after birth for intensive care. The BCG immunisation programme after birth was launched in April 2004. The Paediatrician received training in administration and was able to train all the midwives in the intradermal technique. All infants under the age of 3 months were included at the start. The success of the campaign and any reported side effects are being monitored. Finally a second Paediatric Consultant will be appointed in 2005 which will enable one paediatrician to focus on the paediatric ward an d neonatal and emergency service, and the second to develop the community service further (Child Welfare, liaison with the general practitioners, child protection, learning disabilities etc) 16 This caters for children with learning problems assessed by Mr Freddie Trinidad, Principal Educational Psychologist, who need medical evaluation and possible medication. This service has developed rapidly throughout the year and Mr Trinidad and the Paediatrician meet regularly to discuss common patients and their management. It is hoped with the advent of a second paediatrician that the Clinic can be expanded further, doing justice to this important aspect of ambulatory paediatrics. The paediatrician met with the teaching community at Bleak House to discuss the medical aspects of management of the Attention deficit Syndrome, raising the level of awareness in the schools for this condition. A significant move forward is the appointment of a clinical psychologist with experience in children. Dr Cantos will commence work in February 2005 and the wide gap in the psychological service for children will be closed. The new St. Bernard’s Hospital The Paediatric Department will move to the new hospital in February 2005. The number of children seen in the Rapid Access Clinics The paediatric Diabetic service develops steadily, The Learning Disabilities Clinic Community Paedriatrics The presence of the paediatrician at the Primary Care Centre for 3 clinics per week has forged closer links with the general practitioners. The assistance of those with a special interest in Paediatrics is greatly appreciated: Dr Vasallo (2 year assessments), Dr Risso and Dr Pinto (Paediatric diabetes), Dr Penrice (child protection) and Dr Thoppil (general paediatrics). The Rainbow Ward will have 20 beds, of which 2 are high care and 5 are isolation. In addition there is provision of 2 adolescent beds in private wards. Adolescents are increasingly being incorporated into paediatric care. Children under 16 years will be included. Staff is being briefed in the care and management of adolescents, presenting a new challenge in the care of this age group. On the newborn side there will be a high care unit with better monitoring and the facility of non-invasive ventilation. A dedicated area for paediatric patients in the Accident and Emergency is planned which will improve the assessment and management of children. Department of Anaesthesia and Critical care Substantial progress has been made in bringing the department up to agreed worldwide standards and above and preparing for the move to the new hospital. The department is a consultant led service providing expertise in anaesthesia, critical care, resuscitation (in and out of hospital) acute and chronic pain, and transfer of the critically ill. It has been focal in the education and training of staff in the recognition of the critically ill, cardiac and trauma life support, with Dr Roberts continuing as an Advanced Trauma Life Support Instructor in the UK The appointment of permanent members of staff have helped to stabilise the transition to the new hospital with many new multidisciplinary guidelines and protocols being introduced and bringing up to date evidence based medical treatments and techniques. Dr Rebello has been appointed as the lead in chronic pain bringing with him a wealth of experience and skill. Dr Svendsen brings with him from Sweden a great deal of experience in cutting edge Anaesthesia and Critical Care will be taking a lead in theatres All critically ill patients are now treated by consultants with recognised training in Intensive Care and with improved multidisciplinary working has enabled the GHA to provide a more comprehensive care package to the population of Gibraltar. As the department continues its proactive role within the GHA it looks forward to a bright and dynamic future in the new St Bernards Department of Ophthalmology A final report of our work at the old St Bernard’s Hospital before we said goodbye. The Ophthalmology Service has progressed to a very high standard in the Primary and Secondary care aspect during this year. The Ophthalmic nursing staff, Optometrist and Orthoptist have contributed a great deal to expand the Ophthalmic Primary Care Service. In addition to their routine work, nurses provide vital emergency ophthalmic care. A total number of 385 emergency treatment was offered by the nursing staff. The Optometrist, in addition to her routine work, also supported the cataract waiting list initiative by performing post-operative assessment and refraction for 178 patients in 23 Clinics from January to February. Optometrist routine work involves post-operative refraction, refraction for children and adults, diabetic retinopathy screening clinics, glaucoma screening 17 clinic and a joint clinic with the Consultant Ophthalmologist. The total number of outpatients seen by the Optometrist during this year was 1502. Waiting time for diabetic retinopathy screening is currently 8 months, for routine adult refraction 14 months and for children 2 months. There is urgent need for a low visual aid service for the visually handicapped and we are exploring ways to free some sessions for the Optometrist to establish and run this Service. A Diabetic Retinopathy Screening Service is a very important public health project. Our Optometrist cannot single-handedly run this Service. We need to look into the possibility of involving the other ophthalmic staff such as ophthalmic nurses and Orthoptrist. (Cont.) Routine refraction needs to be directed to the Main Street Optometrists. We are exploring this possibility. The cataract waiting list initiative had a tremendous impact on the waiting list. Over 192 patients cataract extractions were performed by the external team commissioned by the GHA during December 2003. There were many shortcomings of this project due to poor organisation but overall it made a significant impact on the waiting list. The new phaco machine leased for the waiting list initiative and the usage of disposable cataract packs for surgery have doubled the cataract surgical throughput. Eventually the new phaco machine was purchased and it is a great asset to the Unit. I am glad to report that we don’t have a surgical waiting list problem in our Department. Patients were operated within 4-6 weeks from the day of listing for surgery. I think it is a great achievement. During this year we carried out 300 phaco-emulsification cataract surgeries with excellent visual outcome and patient satisfaction. cataract surgery. This year we have performed 315 major ophthalmic surgeries, most of them cataract operations. We have done 69 minor ophthalmic surgical procedures. We offer ophthalmic laser treatment, particularly for retinal vascular problems such as diabetic retinopathy. We carried out 158 ophthalmic laser procedures this year. Most of the workload is in the Outpatient Department. We held 151 general Ophthalmic Clinics this year and roughly 4500 patients attended these Clinics. Tertiary referrals to Moorfields Eye Hospital in London are the patients who need vitreo-retinal surgery, corneal grafting and some required second opinions. These referrals are few in number. The statistics are not available for me to present. There was some disruption to the Orthoptic Service due to the maternity leave of our regular Orthoptist. Locum cover was provided by Mrs Diana Owen who did a good job to continue the Service until she resigned the post due to medical reasons. Introduction of an Orthoptic Service in Gibraltar has tremendously improved paediatric ophthalmic care. We manage to control and treat amblyopia effectively and the incidence of surgical correction of squint in children is reduced to the minimum. The old St Bernard’s Hospital has served the community extremely well, though with its limited resources. We, in a limited space, managed to provide a comprehensive Ophthalmic Service. We performed the latest small incision cataract surgery in a very small room in the Outpatient Clinic with results comparable to modern units anywhere in the world. We perform a wide range of ophthalmic surgical procedures that include phacoemulsification cataract surgery, glaucoma surgery, strabismus surgery and various other minor surgical procedures. The bulk of our surgical workload is By the end of 2004 we are mentally prepared to venture our future in the new St Bernard’s Hospital. There are many challenges ahead of us. Our aim is to achieve a patient focused modern Ophthalmic Service to our people and we are ready to work towards realising this goal. Physiotherapy Services Students Continuing Professional development - CPD Physiotherapy training for 2006 4 students are undertaking Physiotherapy Degrees in the UK. Due to qualify in 2005. Students will then complete 2-year post–graduate Junior Rotations in the UK before applying for posts in the GHA. Courses undertaken as per Personal Development Plan: Individual Physiotherapy Professional Development as per Personal Development Plans: Bank Staff • Angie Fortuna: 8 day Spinal Mobilisations course UK Human Resources Physiotherapy staff • Caroline Vinent- Superintendent II / PAM Co-ordinator • Eddie Linares - Deputy Supt. / Manual Handling Co-ordinator - In-patients • Carole Williams: Senior I -Special Needs / Paediatrics (Maternity Cover -Gail Smith) • Angie Fortuna: Senior I -Out-patients • Janice Wink: Senior I -Community Adults • Lynne MacDonald: Senior II -Rotations (returned from Maternity Leave July 04) List of Registered Bank staff available to cover sick/annual leave. Total of 8 weeks cover was provided (resident Physiotherapist), allowing the service to remain operational in critical areas, whilst providing the local physiotherapist with additional experience/maintaining /building skills following post-graduate rotations in the UK. New Staff • Janice Wink: 2 days Normal Movement UK/ Certificate in Management Course • Caroline Vinent: (PAM Co-Ordinator) 4 days 360 Appraisal and Executive Coaching UK • Eddie Linares: Managing Safely IOSH 4 days MDT GHA courses attended • Orthopaedic Seminar -Physiotherapy contribution by Angie Fortuna • International Nursing Conference 2 days • Tosca Figueredo: Physiotherapy Assistant The recommendation from the Orthopaedic review was for a further 2 Outpatient Physiotherapists. No increase in Physiotherapy staff complement during 2004. 2004//5 Estimates: New Hospital In line with new Services: • Tanya Gilson: Physiotherapy Assistant appointed Sept. 2004* • Hydrotherapy – Physiotherapist and Assistant • Building a Patient Safety Culture and Managing Risk Seminar 1 day C.Vinent • Samantha Victor- Junior Clerical Grade • In-patient Physiotherapist • BLS Update of all staff *Replace existing posts • Community Physiotherapist/out-patient Physiotherapist • Manual Handling Update of all staff • Cathy Pons: Senior II Rotations • Amanda Danino: Senior II Rotations appointed Sept. 2004* • Rehab Clerk • Module in Rehabilitation Practice: 5 days E Linares, L Macdonald, A Danino • ALS 2 day course Janice Wink • Phototherapy Update • ITU Update • Paed Orthotics • Obs and Gynae • Assessment and Treatment of Stroke patients Service requirements • Mandatory training in BLS / Manual Handling / Agenda For Change • Hydrotherapy Course pre-requisite for New Service • Physiotherapy management of the Psychiatric patient. • Management Courses for Senior staff Development of Services - GHA wide • Physiotherapy in Occupational Health • MDT Pain Management • MDT Stroke Management • MDT Spinal Protocol and Study Day/Conference- Shadowing in the UK • MDT Management of the Low Vision Patient 18 19 • Generic Clerical /Reception staff and facilities inadequate • Protocols/Blanket referrals for Orthopaedics not in place. • Hydrotherapy Pool – identified problems with build. • Rehab Stroke Unit: deferred until new Hospital. MDT Management of the stroke patient essential to improve service in this clinical area. • Appropriate Training for Hydrotherapy and ‘Housekeeping’ required. After a busy year of preparations our plan was put in place for move to the new Hospital. Patient services Out-Patients: • Knee specialist and Scoliosis Clinic held in August 04. No Physiotherapy input brought about numerous complaints re on-going Physiotherapy treatment. • MDT Intermediate Care Services package for the Elderly not resourced. Adult Community Focus for 2005-Assisting patients to be treated and supported within their own homes: • Early Supported Discharge Scheme • Rapid Response Service for elderly and frail seen in A/E • Falls clinic • Joint Spinal Clinics with Mr. Malik continued throughout the year. • Improvements within Psychiatry Services. • Increase in Appointments times has allowed the physiotherapist more direct patient contact time and Documentation time. Special Needs Paediatrics: • DNA Policy was more rigidly enforced. Service improvements 2005: • Multi-Disciplinary Backpain Protocol - Research-based management of Back Pain. • MDT Pain Management Service.- pending recommendations from the Audit 2001. • Review Triage and Assessment of Musculo-skeletal conditions on waiting list. • New methods of MDT working with the appointment of 2nd Orthopaedic Surgeon. In-patients • Difficulty with planning of Physiotherapy services as Orthopaedic surgery fluctuates. Paediatric Referrals for the Orthotist are 1st screened by the Paed. Physiotherapist. Orthotics and Prosthetics Patients Appliance Policy and Operational Policy reviewed and financial assistance increased. Data for 2005 Staffing Whole time equivalent New patients Review patients Out-Patients 2.9 WTE 1577 5464 IN-Patients 1.7 WTE 485 Community 1.5 WTE 284 786 Special needs/ Paediatrics 1.2 WTE 58 560 Groups 411 • The 2nd Orthopaedic Surgeon was not appointed delaying improvement in MDT services. Individual Performance Reviews • Foot Audit commenced for Paediatric Orthotist referral. • Staff appraisals including Personal Development Plans carried out. • Are out-patients being over treated? Audit. • Professional Portfolios encouraged. • Best practice and evidenced based working integrated into working practice • Reviewed Guidelines for Referral for In-patients to Community Physiotherapy. through Weekly In-service Training Programme, sharing of skills and use of Library/ Internet service at Bleak House. • Senior Staff have consolidated responsibility for Objective setting and peer reviews within their own clinical area. Health Professions Council All Physiotherapists have current registration with HPC. Clinical Governance Framework workstreams Further work during the year centred on: The New Hospital facility has seen the creation of a proper Occupational Therapy Department with facilities in which we can begin to carry out full O.T. assessments of our patients. This will result in an increase in the quality of our interventions with our clients. We are not fully settled in however; nevertheless the benefits of having moved down are palpable already. The department structure is included in the service distribution map included on the right... Points to Note. • Request for Discretionary points pending since 2000. • The Paediatric OT is working single-handedly. • Request for Clerical post upgrade to AO post and P& P pending. • The need to develop the O.T. helper role within the department. This would maximise treatment slots for patients, with tasks such as cleaning, delivery and collection of equipment being undertaken by a helper. • Request for part-time status made -remains pending. • Discharge Planning Hospital Migration • Orthopaedics- TKR Protocol Risk Factors: • Improvements relating to Clinical Governance work-streams. • Change of date caused some uncertainty. Quality Improvement Programmes 20 Outstanding issues Occupational Therapy Department • Staff resources with regards to New Hospital Services and actual build up to the Move considered inadequate. All the work done in-house. Physiotherapy Services are regularly audited with respects to improvements both in clinical practice and Service standards, egs of which: • Central Stores arrangements not known • Orthopaedic Joint Replacement Audit. • Portering arrangements not known • Documentation Storage not known • The department covers all the broad spectrum of services you would expect from a district service in the UK • The Mental Health OT post role has changed slightly to allow for more time to be available to community patients. It can be considered as two distinct 1⁄2 posts one-half covering KGV and the other covering community mental Health. • Changes from last year include an 0.5 OT post moved from the community setting to the hospital service to provide continuing care needs of patients discharged into the community. It is also a service, which is used to offer 21 support to the needs of palliative care patients wishing to be discharged home. Classification 2004 2003 2002 2001 2000 1999 There has been a slight increase in the waiting list, it has in fact gone up slightly. We are attempting to respond, as time allows, use quieter periods in hospital referrals to attend to community referrals in an endeavour to reduce the community waiting lists. The community Team uses a triage system to ensure the most urgent cases get seen quickly. Service throughput remains at the same levels, though these are provided in spacious and modern surroundings. The O.T. department has submitted it’s operational strategic plan for evaluation by the Executive Board. By location Outpatients 1468 1214 1226 832 869 857 Inpatients 573 910 902 360 296 334 New contacts 722 806 766 547 Not available Follow ups 1319 1318 1362 645 Not available Children (<18) 266 190 219 211 218 222 Adults (>18) 1775 1934 1909 1053 1029 969 Total 2041 2124 2128 1192 1165 1191 Special Thanks By caseload By age group We rely on the help and cooperation of a wide cross section of professionals and individuals to be able to provide the best care possible for our clients especially those out in the community, too many people to highlight all of them individually. I would like however to take this opportunity to thank the following personalities from outside the GHA: Carole Sharrock from the Red Cross; the Building & Works OT section; Staff from the Social Services Department; the members of the Housing Allocation Committee N.B. Cheryl Figueras was appointed in February 2002. Expectations for 2006 1. The improvement of our data collection procedures to exploit the advantages afforded by the new technology provided. 2. The submission of a business case for a full intermediate care service. 3. The creation of a support service network as proposed in our operational plan. Laboratories Service Sponsored patients Staff changes Sponsored Patients is a very busy dynamic department, which is involved in a variety of levels of a patient’s tertiary care. We are made up of one Executive Officer Mrs Carmen Macias and four Administrative Officers, Joanna Ferrary, Jenny Chipolina, Jay Schembri and Sabrina Viales. No staff changes occurred during 2004, although for operational reasons, several locum tenens were engaged from June onwards. The staff complement remained as follows: 4. Job evaluation and a capacity study in the OT services. 5. The creation of an equipment provisioning criteria. 1 x Consultant Histopathologist 6. Improvements in the Information regarding our service available to our users. 1 x Public Analyst/Chief MLSO 1 x Deputy Chief MLSO Department of Nutrition & Dietetics The Department of Nutrition & Dietetics continues to provide a wide variety of services to the hospital and the community. 2004 saw an increase in the number of outpatient clinics due to an increased waiting list. The 5 clinics weekly now include 4 general clinics and 1 paediatric clinic. The total number of patients that the department is able to consult has remained saturated for the past 3 years indicating our limitations for expansion. The majority of consultations for outpatients are related to weight reducing and diabetes whereas the majority of inpatients seen are for nutritional support e.g. tube feeding, intravenous feeding. The department is also involved in health promotion, education and training of other health care staff, cardiac rehabilitation and catering issues. 22 4 x Senior MLSO 3 x MLSO1 5 x JMLSO (including one part-timer) 3 x Clerical Officers 1 x Laboratory Operative. It was hoped that our request for additional staff in 2005 would be favourably met. Courses Mr Alex Menez attended an Olympus Users Conference in Ireland. There was the opportunity to discuss problems that are common to other users, as well as to assess the new Olympus Immunochemistry Analyser and the OLA Pre-analytical module. This course was sponsored by Olympus Optical Spain. Two MLSO’s entitled to attend courses during the year under GHA sponsorship, were unable to do so. Service We continue to participate in the UK National Quality Assessment Schemes for Clinical Chemistry, Haematology and Blood Transfusion Serology, and plan to extend this to Microbiology in 2005. More extensive internal Quality Control work was carried out in Coagulation, and it is envisaged that we will have facilities for similar, increased QC work in Haematology. Changes introduced to improve the Blood Transfusion service are detailed by Ernest Gomez in the sheets appended. A total of 351 patients are on anticoagulant therapy and most regularly attended our Department to have their INR monitored. This number represents an increase of approximately 30% over the previous year. An offer by Palex Medical to provide us with a Tosoh AIA-1800 Immunochemistry Analyser and a Labotech analyser that would automate our ELISA techniques, was readily accepted. The AIA-1800 will take over the workload of the AIA-21 allowing the latter to remain as a back-up. Equipment that had been ordered for the new laboratory arrived and was stored ready to be moved and installed. Towards the end of the year, a date was set by which the new hospital would be operational. Planning the actual move then commenced in earnest The nature of our work involves us making the travel arrangements for a patient and their escort to attend their appointments, liasing with the family to complete the necessary financial assessment prior to their departure which, enables us to provide the vital paperwork they need to take with them. We also deal with the day to day emergency transfers, which can occur throughout a 24-hour period. This involves the officer on call liasing with the Doctors and nurses from our hospital and the receiving hospital, be it in UK or more often Spain. Again we need to prepare the fundamental paperwork and arrange the Ambulance so the patient is transferred according to their medical needs and in an efficient style. We need to prioritise our work and deal with the task in hand in a methodical way. This ensures that the patient and there family are aware throughout of what is happening which helps them in this stressful situation. We also deal with the reimbursement of travel and maintenance allowances to the patients and escort on their return to Gibraltar. Once a week we also work paying the nursing escorts who do the essential transfers to Spain their allowances. This department’s workload has grown significantly over the last twelve years as shown below. One of the obviously changes over these years is the increased volume of patients visiting the Spanish Hospitals in the Andalucia area. 23 In conclusion the year 2004 to 2005 has been a busy year for the department with a growing amount of referrals to UK and Spanish hospitals. The work has however been consistent and with the usual emergencies throughout the year. The team in Sponsored patients works very closely both internally and externally to ensure the demands of the patients are met no matter what the workload. Pharmacy 1. Highlight of this year is successful move to new Hospital which has provided us with a much better working environment 2. Services provided are principally the same, except now both surgical and • medication for our Haemophiliac, • new drugs (pain relief-eg durogesic patches and psychiatric-eg risperdal consta inj) • increase in demand of wound dressings both medical wards are issued their medication on a named patient basis • increase in demand of feeds for dietician 3. No change in staff compliment – stores assistant still on roll-over • increase in demand of expensive iv antibiotics (as set out in new policy) contract • increase in demand of i. v fluids 4. Major overspend on allocated drugs budget (Budget £950,000, actual • increase in demand of anaesthetics / pain relief theatre spend £1,444,409) This increase in spend is attributable to various factors; • increase in demand of drugs for intensive care . • opening of new hospital • increasing demand of drugs by new doctors introducing new policies and • new vaccination programme (BCG, 3 in 1, 4 in 1 an 5 in 1 vaccines), procedures (eg pain clinic) • vaccination for all grades hospital staff, emergency services (Fire brigade, • two extra floors of ECA (patients from Lewis Stag and Lady Begg ward) RGP,Prison,customs etc),ECA staff, students • drugs for major cataract initiative Information Management & Technology In February 2005, with the move into the new hospital, the Authority IMT Department turned a new page in its application of technology towards the improvement of healthcare in Gibraltar. It has worked towards achieving the overall strategic aims of the Authority to improve clinical outcomes and corporate performance. The focus was given the following development themes: • Improving and making maximum use of the physical infrastructure • Maintaining ordered and well-planned Networks and services • Creating working relationships with Government Departments & agencies • Promoting the use of Science and Technology in Health Care; • Increasing the number of PC’s throughout the GHA • Providing clinical and other areas with support required • Developing software to enhance the patient experience • Developing software to assist clinicians and management • Working towards an electronic patient record • Leading in the development the European Health Insurance Card Major investment has been made, and continues to be made, at many levels to enable the delivery of dramatic improvements to customer service, quality, 24 operational effectiveness and value for money. At the beginning of the year external consultants were commissioned to advise on a Health Care IMT Strategy. This entailed a comprehensive review of existing health systems and existing practices. The consultants also made recommendations on the structure and development of the IMT Department. The report contains recommendations that include the introduction of modern and efficient standards of health care process and regulation as well as functional programmes for the new hospital. The Government and the Authority have accepted the recommendations of the report and the Authority will now be seeking proposals, on an EU wide basis, to assist the Authority in achieving these aims. Technology is growing at an aggressive rate within the GHA. Developing a sound relationship with public sector resources is crucial to the future delivery of healthcare. Mutual co-operation with public sector resources not only makes economic sense but is recognised as a prerequisite to our success. The Government Information Technology & Logistics Department (ITLD) and Gibtelecom have proved great partners to achieve the delivery of the first phase of works. We have every confidence that this will continue well into the future. The Authority has maximised the use of the high capacity link installed by the Government, under the auspices of the ITLD, and this has provided quality connectivity between, for example, St Bernard’s Hospital and the Primary Care Centre. The overall objective of the initiative is to improve the quality, efficiency, 25 and effectiveness of the healthcare services with real savings and cost-effectiveness. Advantages Within the space of a few months, the GHA has tripled the number of PC’s and users that have access to email and internet services. Doctors now have direct internet access to critical services like poison centres and other online information sources. Communication throughout the organisation is faster and more efficient. • Almost 300 individual lines have been disconnected and now run under a call managed operation; A bed management system was developed in house and is already in use widely. This enables in-patient tracking and bed usage statistics. A history of admissions for each patient is being stored electronically. On-screen ward layouts are available in all wards and Accident & Emergency, with room and bed distribution, showing where patients are located in each ward, what phone extension the patient is at, and which bed is available in any given ward. In order to assist the families of the patients with their queries, some of this information is readily available to the staff at reception. • GHA has invested in a long term switching hardware, software and network that allows for future expansion and converging of data and voice services thus making the carrying of these services more economical and efficient in-site and of-site. In a move away from the traditional paper list, and as an extension of the system that has been in operation at the Primary Care Centre for over a year, a GHA wide appointment and scheduling system is already in place with appointments for clinics being made electronically. The Radiology Department now operates powerful digital imaging equipment where X-rays, scans and other images are stored electronically on servers. These images will soon be available for doctors to view on screen at their clinics. Similarly, tests conducted by the pathological laboratories will soon be available to clinicians electronically. Information Technology will enhance healthcare in Gibraltar. The seeds have been sown. The move towards the Electronic Patient Record has begun. Telecommunications Report At the old Hospital Site GHA operated a Centrex phone system for internal • GHA now has the ability to deliver and monitor Patient services as well as providing statistics on things such as appointments etc. • Monitoring and access control tools available on the PBX have reduced GHA’s overall phone bill amounts. • The transitional over-haul of the entire numbering strategy has significantly assisted the production of a telecommunications policy for the “New GHA”. Records Department This year has seen major changes and improvements to the Medical Records Department following the move to the New Hospital. The first challenge faced was the migration of the Medical Records Department from old St Bernard’s to the New Hospital while causing the least disruption to the general public and staff. I take this opportunity to thank all the staff that made this possible for their unconditional support. The department in keeping with its strategic objectives, has carried out a role re-design exercise, which resulted in splitting of the functions of appointment scheduling from that of medical librarianship. This entailed moving appointments scheduling to first floor reception near the Out Patients clinics whilst keeping the Medical Library at Ground Floor level. service users , and Gibtelecom service on outside lines. All incoming/outgoing internal or external GHA calls were routed and switched individually from the Gibtelecom, System X exchange into the GHA across Gibtelecom’s copper network. Gibtelecom owned and managed all the communications equipment We have also extended our services by providing an administrative officer in the Ophthalmic Department Reception to cater for all service requirements & queries in this Unit. This has been possible due to the increase in staff compliment by a further five administrative officers. necessary to implement PBX facilities and would sell services to the GHA. The main number for the GHA and St. Bernard’s Hospital was (and still is) 79700, and the service was manned by Hospital Attendants. GHA also rented individual Centrex lines for use as exchange lines to and from the Primary Care Centre in Secondary sites i.e. Johnston’s Passage and Bleak House also operated Weekly Audit reports on performance by the Records Department show an increase in compliance of availability of medical folders. In addition, the Gibraltar Health Authority has contracted the services of Micro Business Systems Ltd to undertake a process of weeding and bar coding of all patient medical files in Records library. on Centrex. This exercise commenced in March 2005 and is being carried out as follows: Background phone services and extensions directly from Gibtelecom and individual • All files are being labelled with name, date of birth, reference number and barcode and entered in a patient database. This will lead to the introduction of files electronically tracked using bar code readers. on-site phones as required. Individual phone lines had to be ordered from • Weeding of non-active files for the last five years and archiving in Records Stores. Gibtelecom, and the company would install individual line to site and to the the new established call-centre / Helpdesk. For general undirected access and • Colour coding all files. This will enable efficient and accurate retrieval and filing of Patient files. quality call management the GHA intercepts calls in this call centre during We envisage that this exercise will be completed within the next couple of months. the main operating times and this allows for porters to avail themselves for prompt that requests the extension required. FrontDesk, the new computerised appointment system introduced in the Primary Care Centre in the summer of 2003, has also been introduced very successfully at St Bernard’s Hospital in August 2005. This has given us the opportunity to be able to follow patients’ history from primary to secondary care and provide a much enhanced service to the public. The PBX is providing the GHA with cost saving and service advantages over Reception the previous outsourced operation. This has included bulk reduction in paid A new front of house service was created with the addition of the role of Helpdesk/Telephonist. The new system became operational in February 2005, in order that it coincided with the opening of the New Hospital facility. This new role was to include the manning of the main reception desk from 08.00 to 20.00 Monday to Friday offering a new front of house professional approach in the welcoming of patients and visitors to the hospital. The service as well as providing a telephone and helpdesk service at the main reception counter, also includes the manning of the Hospital communications centre. The centre provides the 24hrs monitoring of the Building Management Systems as well as the Fire Prevention Systems. The Helpdesk staff at St. Bernard’s are integrated into the Primary Care Advanced Appointments telephone lines in order to assist Primary Care in dealing with advance appointments, and thereby improve the service provided to our clients. the ICC to communicate internally and with the rest of the authority in order to save on local call charges. GHA before inaugurating it’s new Hospital traditionally purchased all final it’s location. Gibtelecom would submit charges for all telephone moves, additions, and changes. This type of service had worked fairly well for the GHA with the previous building and operational strategy. However, the costs of lines, moves, additions, and changes became increasingly expensive as the organisations communications requirements grew, and the systems became outdated and incompatible with the technological requirements of a modern healthcare facility. As part of its telecommunications strategy for the New Hospital the GHA purchased a state of the art internal phone system, a PBX (private branch exchange) manufactured by Northern Telecom using traditional voice and Internet voice protocols. As part of the construction programme the building was pre-wired with approximately 2500 structured wiring points capable of delivering both data and voice. The facility being spread over six server rooms across the hospital. 26 • GHA has reduce significantly high charges for moves, additions, and changes of any telephone lines and services; direct patient services. An additional system available to incoming traffic is an automated or through dial system for personal or indirect traffic. This is a voice up lines, with a total disconnection of over 300 previously rented lines. With the multiplexing of traffic on PRI (Primary Rate Interface) links to Gibtelecom and the commencement of Voice over IP service for converging telephony and data over existing links to sites like Primary Care Centre has saved on past individual links for all the different services. A large number of “internal” extensions operate with specific features and control for professional Patient The approach has been to use some of the existing operationally required orientated quality call management services. Some of the end-user features will external direct numbers routed through 2 PBX PRI links. These are large improve communications and mission-critical functions at GHA, including, capacity telephony cables carrying 30 simultaneous calls each in and out of the roll-overs, hunt-groups, multi-call ringing and broadcast messages through GHA and delivered to the required extensions either automatically or through voice-mail etc. 27 Valedictory 1567-2005 This year, St Bernard’s Hospital was transferred to the new building in Europort. This is an important, forward-looking move, which should transform the delivery of medical care in Gibraltar – truly a hospital for the new millennium! But before we advance starry-eyed into the future, let us for one nostalgic moment look backwards at the building we have left. Yes, the old hospital, with its jumbled architecture, its crumbling infrastructure, its maze of corridors. But how many generations of Gibraltarians were cared for there? It was founded in 1567, when Shakespeare was a toddler! For four hundred and thirty eight years, it looked after Spanish inhabitants, sailors, soldiers, and for the last 190 years, it served us, the Gibraltarians. And, with all its perceived deficiencies, it served us well. Here is a brief timeline, to give us a feel for the venerable history of the building: 1567-1591: Founded by Juan Mateos, a retired innkeeper, to treat sick sailors (Don’t ask!) 1591-1704: The Hospital de San Juan de Diós, run by monks, for the treatment of infectious diseases. 1704-1756: After the capture of Gibraltar, it was used as a hospital for soldiers and sailors, until the Old Naval Hospital was completed in 1746. After that it became the ‘Garrison Hospital’. 1756-1815: The building was converted into a barracks – the ‘Blue Barracks’. The Company of Military Artificers (the forerunners of the Royal Engineers) was formed here in 1776. The building was severely damaged by bombardment during the Great Siege, and remained in a ruined state for over 30 years. 1815-1889: The Civil Hospital was built on the site by General George Don, the Lieutenant Governor. This was the first hospital for the whole civil population for over 100 years. It was divided into Catholic, Protestant and Jewish sections, each managed by a committee from the respective community. 1889-1963: In 1889, the management was taken over by the Colonial Government, and it became the Colonial Hospital. 1963-2005: St. Bernard’s Hospital The new St Bernard’s Hospital has many sophisticated facilities which were not available in the old building. But these will serve for little if those working in it do not follow the shining example of old Juan Mateos, who consecrated his life to caring for the sick, and of the many devoted doctors and nurses who followed him over the centuries, and of forward-minded administrators like George Don. The new hospital, I fear, does not lack for carping critics: It will thrive, in spite of its malingers, if it takes action where criticism is justified, but for the latter, it can do no better than to adopt as its motto the phrase that old George Don was fond of quoting to the recalcitrant inhabitants of Jersey, his previous posting, when they opposed his reforms. “Je vous ferais du bien malgré vous!” (“I will do you good, in spite of you!”) Sam Benady, Retired Consultant Paediatrician 28 29 Statistics 2004 Public Health 2004 Births in Gibraltar by location (2004) Location Female Male Total Percent 1 15 207 223 1 22 175 198 2 37 382 421 0.5% 8.8% 90.7% 100.0% Home Royal Naval Hospital St. Bernard’s Hospital Total Births to mothers over 35 (2004) Age of Mother 35 36 37 38 39 40 41 42 44 51 Total Female 7 6 7 6 2 4 1 1 Male 9 5 9 3 2 4 3 Total 37 16 11 16 9 4 8 4 1 2 1 72 Female Male Total 1 12 203 4 3 223 5 187 5 1 198 1 17 390 9 4 421 Age at death Female Male Total <44 45-54 55-64 65-74 75-84 >85 Total (%) 3 1 7 13 45 42 111 50.2% 2 2 6 25 48 27 110 49.8% 2 1 35 Births by birth weight (2004) Birth weight <1499g 1500-2499g 2500-4499g >4500g Unspecified Total Deaths by age and sex (2004) Births by month (2004) Month January February March April May June July August September October November December Total Female Male Total 20 17 21 17 18 14 22 15 24 18 19 18 223 21 16 12 15 18 18 13 5 21 16 20 23 198 41 33 33 32 36 32 35 20 45 34 39 41 421 Female Male Total 5 3 13 38 93 69 221 100.0% (%) 2% 1% 6% 17% 42% 31% 100% Births to teenage mothers (2004) Age of Mother 14 15 16 17 18 19 Total 30 1 1 6 4 4 1 16 3 1 2 7 1 1 6 7 5 3 23 31 Deaths by place of death (2004) Place of Death St. Bernard’s Hospital Home Mount Alvernia Jewish Home Elsewhere K.G.V. Hospital Total Female 87 13 8 2 1 Male Total 94 11 3 1 111 1 110 181 24 11 3 1 1 221 Female Male Total 25 18 25 19 11 6 1 5 110 49 34 50 36 27 14 1 10 221 Cancer incidence: selected anatomical sites cumulative (1998 – 2004) (%) 82% 11% 5% 1% <1% <1% 100% Site Deaths by cause and sex (2004) Cause of Death Heart disease Cancer Stroke Respiratory diseases Infections Degenerative diseases Accidents & Injuries Others Total 24 16 25 17 16 8 5 111 (%) 22% 15% 23% 16% 12% 6% <1% 5% Heart disease Cancer Stroke Respiratory diseases Infections Degenerative diseases Accidents & Injuries Others Total 73 59 31 29 11 5 10 23 241 1999 2000 Organism 100% 87 52 40 39 8 11 9 21 267 2001 90 60 18 15 6 23 9 12 233 75 53 18 24 6 18 3 18 215 Cancer deaths by site (2004) Site Prostate Pancreas Colon Breast Melanoma Lung Stomach Pharynx Kidney Bladder Brain Occult Uterus Oesophagus Ovary Myeloma Parotid Lymph Biliary Liver Total 32 Female Male Total N/A 3 3 4 1 1 2 1 0 1 1 2 1 1 1 0 1 1 1 0 25 8 3 3 0 2 2 0 1 2 1 1 0 0 0 0 1 0 0 0 1 25 8 6 6 4 3 3 2 2 2 2 2 2 1 1 1 1 1 1 1 1 50 2002 77 48 21 48 8 13 1 15 231 333 80 37 35 17 17 16 15 15 70 635 Laboratory confirmed infections (2004) Trends in cause of death (1998 – 2004) 1998 Registrations Skin Breast Uterus & cervix Colon Stomach Bladder Prostate Oral cancers Lymph nodes Other cancers All cancers 2003 62 66 37 23 13 17 6 7 231 2004 49 50 34 36 14 27 1 10 221 Salmonella Campylobacter Shigella Giardia lamblia Myco. tuberculosis Cryptosporidium E coli 086: K61 E coli 0111 :K58 Trichomonas vaginalis Chlamydia Bartonella (Cat scratch) Mycoplasma pnuemoniae Adenovirus Rotavirus Respiratory Synctitial Virus Hepatitis C Hepatitis B Hepatitis A IgM Total Jan Feb Mar Apr May Jun Jul Aug Sep Oct NOV Dec Total 2 2 1 7 1 4 1 5 5 5 6 8 4 1 27 5 16 3 6 2 3 5 2 6 2 1 90 32 8 1 2 2 1 1 3 8 1 1 19 14 8 3 3 2 199 1 2 1 1 1 1 1 1 1 1 1 1 1 3 1 1 2 4 4 10 9 1 1 1 1 1 13 1 4 3 1 2 1 10 1 12 12 14 38 33 1 1 6 3 1 1 14 9 19 15 Trends in MRSA infections by probable source (1994 – 2004) Source Imported Community Intrinsic Hospital Acquired ECA Indeterminate Total 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 All years 1 2 1 1 2 1 3 1 1 7 5 9 3 2 2 2 6 1 4 4 4 1 1 4 18 1 15 13 10 6 2 1 3 1 1 14 3 9 4 6 5 6 33 40 32 8 18 6 13 117 1 4 3 4 1 2 (%) 34% 27% 7% 15% 5% 11% 33 (Cont.) PATHOLOGY Health Care 2004 PATHOLOGY 2004 323,477 8,293 376,906 9,387 25,223 22,275 2,454 602 1,969 487 830 636 Coagulation: 6,106 7,373 Samples Gynae Cytology: 1,468 1,256 Cervical Smears Histology: 1,247 2,712 477 1,217 2,496 1,050 Specimens Deep cut requests Extra blocks 100 1 62 0 0 4 1 0 0 0 7 0 0 92 6 84 2 4 4 1 9 2 0 2 0 0 PAS PASd ABPAS ABPAS low pH Mast Retic Grams Perls Giemsa ZN Unna Apap EVG MGP 0 1 0 12 3 2 Imprints Decalcification Dekeratinisation 181 8 0 3 1 7 9 8 144 8 3 5 1 5 8 3 0 45 18 5 5 5 0 2 3 10 32 14 4 1 51 9 2 4 2 1 3 8 16 13 13 0 Haematology: Blood Group Serology: Blood Donors: Surgical Cytology: FNAB: 0 34 2004 40 40 3 18 18 0 Microbiology: 4,801 3,089 1,430 610 388 58 81 92 3 3,941 2,914 1,185 632 259 38 42 53 3 Urines Swabs Stools Blood Cultures Sputum Seminal fluid TB Cultures Mycology Cerebrospinal fluid Viral Serology: 6,647 6,553 Investigations 2003 Clinical Chemistry: 2003 Total investigations. TSH Samples Group and Antibody Screen Antibody Screen Bled and Screened Specimens Ascites Bronchial brushings Bronchial washings Buccal mucosa smears Cyst fluid (NOS) Cyst fluid ovary Douglas Pouch fluid Branchial Breast Lymph node Parotid Thyroid Other Hydrocoele fluid Knee aspirate Peritoneal fluid Pleural fluid Sputum Urine Other Samples Referred: Public Analysis 756 964 179 202 378 352 234 45 29 PAS PASd MGG Doctor’s Laboratory Arrimada’s Lab Sheffield Children’s Hospital PHLS/Northwick Park Royal Marsden 2003 2004 Food and Drink: 205 273 Samples Potable water, Civilian: 209 224 Samples Potable water, MOD 306 577 Samples Deionised water: 34 35 Samples Sea water: 156 157 Samples Swimming pool water: 33 79 Samples Filtrations: 13 17 Samples Atmospheric pollution, SO2: 728 728 Samples GHA Expenditure 2004/05 Pay & Related £23,117,859.00 Drugs & Pharmaceuticals £10,059,172.00 Interest, Leases & Accommodation £4,849,148.00 Sponsored Patients & Visiting Consultants £2,196,319.00 Other Operational £1,999,543.00 Dressings / Gases & Tests £1,273,109.00 Non-GHA £919,123.00 Insurance, Fees, Claims £857,927.00 Med & Surg Appliances £563,880.00 Elec, Water & Tels £538,651.00 School of Health Studies £204,964.00 Capital £61,727.00 TOTAL €£46,641,422.00 35 Notes Sponsored patients Amount of Patients Financial Year 1992/93 U.K. Spain 295 Total 295 U.K. Spain 446 Total 446 1993/94 329 3 332 517 3 520 1994/95 372 5 377 599 6 605 1995/96 386 5 391 666 5 671 432 11 443 653 11 664 1997/98 480 27 507 763 45 808 1998/99 545 32 577 827 50 877 1999/00 566 58 624 889 70 959 2000/01 1996/97 573 69 642 1,034 115 1,149 2001/02 599 117 716 966 206 1,172 2002/03 631 185 816 1,090 393 1,483 2003/04 679 259 938 1,164 598 1,762 2004/05 753 291 1,044 1,252 644 1,896 Sponsored Patients number of referrals 04/05 Sponsored Patients number of referrals 02/03 UK Hospitals UK Hospitals Total Total St Mary’s Hospital 354 St Mary’s Hospital 341 Royal Marsden Hospital 291 Royal Marsden Hospital 266 Moorfields Hospital 81 Moorfields Hospital 85 Charing Cross Hospital 26 Charing Cross Hospital 31 Hammersmith Hospital 21 Hammersmith Hospital 27 Leicester Royal Infirmary 54 Leicester Royal Infirmary 27 The Middlesex Hospital 42 The Middlesex Hospital 26 Guys Hospital 64 Guys Hospital 24 Kings Healthcare 22 Kings Healthcare 24 Spanish Hospitals Spanish Hospitals Hospital Materno Infantil Malaga Hospital Materno Infantil Malaga 75 Hospital Universitario Puerta Del Mar Cadiz 342 Hospital Universitario Puerta Del Mar Cadiz 74 Hospital de la Seguridad Social La Linea 137 Hospital de la Seguridad Social La Linea 30 All other Hospitals 424 All other Hospitals Total 36 Amount of Referrals 40 1898 Total 242 1272 Notes