health matters 2014/15 - gibraltar health authority · 2018. 3. 16. · the 2012 census of...
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Health Matters 2014/15Gibraltar Health Authority
Foreword by the Minister for Health and Environment 5
Introduction by Fred Pitto, Chief Executive 7
1. PUBLIC HEALTH 8
1.1 CENSUS 2012 9
1.2 VITAL STATISTICS 9
1.3 HEALTH & LIFESTYLE SURVEY 12
1.4 CANCER REGISTRY 13
1.5 COLON CANCER SCREENING
PROGRAMME 16
1.6 ABDOMINAL AORTIC ANEURYSM
SCREENING PROGRAMME 17
1.7 INFECTIOUS DISEASES 18
1.8 HEALTH IMPROVEMENT 22
1.9 AIRFIELD INCIDENT EXERCISE 2015 30
1.10 IIPHF CONFERENCE 2015 31
2. PUBLIC ANALYST 32
3. DIABETES SERVICES 34
4. PRIMARY CARE SERVICES 37
4.1 PRIMARY CARE ADMINISTRATION 38
4.2 DENTAL DEPARTMENT 38
4.3 PRESCRIPTION PRICING AND
ADVISORY UNIT (PPAU) 39
4.4 MEDICAL SERVICES 41
4.5 PRIMARY CARE NURSING 41
4.6 OTHER SERVICES 44
5. SECONDARY CARE SERVICES 46
5.1 AMBULANCE SERVICE 47
5.2 A&E DEPARTMENT 48
5.3 HOSPITAL OPTOMETRY 49
5.4 ORTHOPTIC DEPARTMENT 50
5.5 OPHTHALMOLOGY 52
5.6 SPEECH AND LANGUAGE THERAPY 52
5.7 MENTAL HEALTH SERVICES 55
5.8 DEVELOPMENTS IN 2014 58
5.9 BED MANAGEMENT 60
5.10 CANCER SERVICES 60
5.11 OUTPATIENT SERVICES 62
5.12 OPERATING SUITE 63
5.13 WARDS AND DEPARTMENTS 65
6. DIAGNOSTIC SERVICES 68
6.1 PATHOLOGY 69
6.2 RADIOLOGY SERVICES 70
7. THERAPY SERVICES 73
7.1 PHYSIOTHERAPY SERVICES 74
7.2 OCCUPATIONAL THERAPY 74
7.3 NUTRITION AND DIETETICS 76
7.4 PHARMACY 76
8. IMPROVING QUALITY OF CARE 78
8.1 LICENSING OF DOCTORS 79
8.2 SAFEGUARDING ADULTS AT RISK 80
8.3 COMPLAINTS HANDLING SCHEME 80
9. SCHOOL OF HEALTH STUDIES 83
10. MANAGEMENT 87
10.1 SPONSORED PATIENTS 88
10.2 HUMAN RESOURCES 89
10.3 DEVELOPMENTS 90
10.4 CORPORATE SERVICES 92
10.5 INFORMATION MANAGEMENT
AND TECHNOLOGY 97
10.6 ELECTRONIC PATIENT RECORD 99
10.7 ESTATES AND CLINICAL ENGINEERING 101
10.8 FINANCE & PROCUREMENT 104
11. APPENDICES 107
Health Matters 2014/15Gibraltar Health Authority
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As Minister for Health during the time covered by this report, I am thrilled to be introducing it to you.
The period covered by the report saw tremendous progress in improving Gibraltar’s health service, with reducing waiting lists, vastly increased numbers of operations performed, thousands more appointments across many disciplines, improved access to visiting Consultants, and much more.
At the same time the Unit-centred management structure began to show dividends, and increasing involvement of clinical staff in discussions and decisions began to bear fruit.
Improved on-the-ground facilities also came into operation, notably the move of mental health from the archaic ‘KGV’ to the award-winning Ocean Views, and the bringing of our catering facility from the windswept North Mole home to St Bernard’s itself.
As I leave the Chairmanship of the Gibraltar Health Authority after five years, you will forgive me if I recall with fondness, not just the last five years, but my time over nearly 30 years, as Hospitals and General Manager, and later on the Board. Working in Health is a privilege. It brings you into contact with committed professionals, dedicated support staff, and a great deal of humanity. It is special and gives you something special, and is something to be cherished.
I thank everyone who made my journey through the health service – at every stage – the experience it has been, and with the GHA, its teams and its users, every success in the years ahead.
With great fondness and best wishes
John
Dr John Cortes MBE MP
Minister for Education, Heritage, Environment. Energy and Climate Change
Minister for Health and Chair, GHA 2011-2016 HM GOVERNMENT OF GIBRALTAR
Foreword by the Minister for Health and Environment
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Once again it gives me great pleasure to introduce the Gibraltar Health Authority’s (GHA) annual report for the period covering 2014 and 2015.
The GHA provides a comprehensive range of health services for the people of Gibraltar, which includes Primary, Secondary, Mental Health and the Ambulance Service, together with tertiary care services provided in either Spain or the UK.
Whilst most of you may be familiar with our front line services at the Primary Care Centre, the Accident & Emergency Department or even the Ambulance Service, there are numerous departments which may not be that obvious to the general public, but essential in the delivery of healthcare. The annual report provides an opportunity to showcase all services giving the reader a greater understanding and insight of most of the departments within the GHA.
The report outlines the work carried out by the GHA over the years 2014 and 2015, highlighting the success and also the challenges faced. All of us at the GHA are committed to provide the best care to our patients and the quality of the care we aim to provide is our absolute priority.
On my appointment as CEO, my initial two priorities were setting up the new Senior Management structure and the development of the three year strategic plan for the GHA. The strategy sets the direction of healthcare for the next three years, identifies the priorities, describes what will be done, individual responsibilities, outcomes and benefits, together with an opportunity for the GHA to be measured on achievements and performance.
These two aspects have ensured that the GHA has the right leadership and clinical/corporate governance structures in place.
As you go through the report, one appreciates the numerous accomplishments despite the challenges faced. The main achievements have included the new Mental Health Facility (Ocean Views), the new Catering Facility, reduction of waiting lists and waiting times as a result of the success of Day Surgery and increased theatre activity. Others have included the introduction of a new appointment system at the Primary Care Centre, improved Cancer Services and the implementation of Phase One of the Electronic Patient Records Programme.
New systems have been introduced such as the Complaints process which is now managed by the Complaints Handling Scheme which comes under the umbrella of the office of the Ombudsman. The aim of this is to provide a more independent and transparent complaints system.
Achievements have also been made in staff training and development with the first cohort of Degree nurses graduating, the introduction of a Master’s Degree programme for senior staff, the introduction of enrolled nurse training, appraisals for all doctors and the partnership developed with the University of Gibraltar which will see many learning opportunities for our staff.
All of this has only been possible through the quality of the GHA’s leadership and the dedicated and professional staff that we have.
Although quite a lot of progress has been made during these two years, we all acknowledge that there are still gaps in the service which need to be addressed such as keeping the Primary Care Centre appointment system under continuous review, alleviating the pressure in our Accident & Emergency Department and the pressures placed on our bed capacity by elderly patients who do not require an acute hospital bed to name a few.
There is still a huge amount to do, but I am optimistic that we are moving in the right direction.
The future will see many new developments such as the new Chemotherapy Unit which will allow the GHA to repatriate this service and the much needed Dementia Day Facility, but the future will also bring uncertainty which the GHA needs to plan very carefully to address potential difficulties such as the Brexit vote and the future of Gibraltar being outside the EU.
Finally, I sincerely hope that you enjoy the report and in the process gain a greater insight into the GHA, its staff and services.
I would like to thank all of our staff who work across the GHA, for the service they provide to our patients and our community, and the dedication and commitment they have continued to show throughout this period, without them none of the achievements would have been possible.
Introduction by Fred Pitto, Chief Executive
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1.1 CENSUS 2012
The publication of the report of Census 2012 in mid-June 2015 was a significant event for public health. This is an important public event that had occurred regularly every ten years, but had been seriously delayed. Firstly, the date of collection was delayed from 2011 by one year, an act that is unprecedented in Gibraltar history, other than during the war years. This meant that while every previous Census is counted at ten year intervals, this census has to be counted at an 11 year interval and presumably its successor in 2021 will be at a 9-year interval. Secondly, the analysis took 2½ years to carry out it until it eventually arrived in 2015.
There is clearly a wealth of information in it, but a glimpse of it may be had from the Population Pyramid in the Appendix, which shows striking gender differences and longevity patterns.
The 2012 Census of Gibraltar is a record of information about the individuals of the Gibraltarian population resident on Census Night, 12th November 2012.
PersonsThe total population counted was 32,194, which is the highest ever on record. It is also the highest percentage increase for each census with a 17% population increase since 2001.
Census 2012 is also noteworthy for counting the largest number of Gibraltarians to date, 25,444, an increase of 11.2%. However, the biggest increase was from 1991 to 2001, when Gibraltarians increased by 14.3%. The Gibraltarian sub-population has constituted around 75% of the population throughout the different censuses taken, although in 2001 it was at its peak with 83%.
The Moroccan sub-population has dramatically fallen from 2,798 to 522 a seemingly precipitous decrease of around 80%. However, this may be an artefact, largely due to many in this group acquiring British citizenship in recent years. This group also
tends to be mobile and some undercounting is also likely.
In terms of age profile, the largest increase in the resident population, when comparing the 2012 census to the 1970 census, is in the group aged 80 and over. This group has increased by 1,054 persons, an average increase of about 42% per decade.
In more recent time, the biggest difference between the 2001 and 2012 Census occurred in persons under 15 years of age, with females in this category increasing by 17.7% and males by 13%. This appears to be largely due to Gibraltarian births.
HouseholdsThe Census also recorded the address of the individual, making it possible to measure the size of the household. The average household size has shrunk over the decades, in contrast to the population which is increasing. This suggests a greater supply of housing, as well as social trends.
1.2 VITAL STATISTICS
PopulationThe Government Statistics Office estimated that the resident population on 31st December of 2014 was 33,140. Such estimates are only approximate, being based on calculations of numbers of persons entering and leaving Gibraltar, but it suggests that the population has been growing at a rate of about 1.5% per annum.
BirthsThere were 439 births in Gibraltar In 2014, and 459 births in 2015, a small but steady increase over the previous years and this maintains the trend in recent years. There were two stillbirths in 2014 and one 2015.
The crude birth rates calculated for the last five years were 15.0% in 2011, 14.7% in 2012, 13.9% in 2013, 13.2% in 2014 and 13.9% in 2015. After the peak in 2010 when it reached 16.4, the crude birth rate may be returning to the normal pattern of earlier decades, during which the birth rates
1. PUBLIC HEALTH
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of the local population had been lower, the average crude birth rate for 1998 to 2002 being 13.9%. However, as these rates use population estimates as denominators, it is important to keep in mind that there could be a margin of error in the calculations.
The absolute number as well as the proportion of births to non-British nationalities has slightly increased – in 2013, there were 36 such births (8.2% of all births), whereas in 2015, this increased to 43 (9.4% of all births).
The number of births in the British Forces sub-population has fallen dramatically, with 3 (in 2015) and 6 (in 2014), from 15 in each of the previous two years. These now form less than 1% of all births, which is much reduced from around a decade ago, when the proportion of Forces births used to be around 8% of all births in Gibraltar.
The see-sawing of male and female births continues as a curious phenomenon in Gibraltar. Until 2002, male births predominated over females every year. From then on, females have predominated during even years and males during odd years. This oddity continues for the fourteenth year in a row, with females predominating at 51% in 2014 and males predominating at 53% in 2015.
All but one birth in 2015 took place in St Bernard’s Hospital.Teenage pregnancies are used as a measure of a nation’s reproductive health in youth. Generally, having children at young ages can give rise to unsatisfactory health, psychological and social consequences for both the young mother and her baby. In the last four years, the number of teenage pregnancies appears to have reduced, 19 (2012), 13 (2013), 14 (2014) and 8 (2015), which is a welcome trend.
The proportion of mothers over the age of 35 seems to have settled at around 20% throughout the last ten years. The proportion of mothers aged 40 and over was constant at 4.8% of all births, during the two years with 21 births in 2014 and 22 births in 2015. This
is an increase over previous years. The oldest mother in 2014 was 43 years old and in 2015 was 47 years old.
Only 13 babies (3% of all births) were born in 2014 with birth weights below 2500 grams. This slightly increased to 4% in 2015, with 19 babies being born with birth weights below 2500 grams. The average birth-weight remains stable: in 2014, the mean birth weight of all babies was 3377 grams (7lb 7oz) and 30.1% of all births fell within 5% of this parameter; while in 2015, the mean birth weight was 3364 grams (7lb 6.7oz) and 26.8% of all births fell within 5% of this.
All this suggests that the general health status of newborn babies is good.
DeathsThe average Life Expectancy in Gibraltar is in line with the best of European standards.
In 2014, there were 240 deaths in the resident population, giving a crude death rate of 7.2, which is similar to that of recent years. In 2015, there were 208 deaths, giving a crude death rate of 6.3.
The mean age at death of males in the resident population rose in 2014 to 78.9, compared with previous years at 76.4 in 2012 and 74.3 in 2013. It fell again to 72.7 in 2015. As for females, the mean age at death also rose, to 83.3 in 2014 but fell to 82.2 in 2015, compared to the previous years at 82.8 in 2012 and 80.9 in 2013.
Over the last four years, this averages to 74.3 years for males and 82.4 years for females. Overall, this is a very good standard of longevity for both sexes and shows that people are living longer. Continuing from previous years, the figures also suggest that the gap between the sexes is narrowing.
There were no deaths in infants or young persons (in 2014). The age of the youngest person to die in 2014 was 20, but in 2015, one child died aged 3.
It is common practice to calculate the extent of “premature deaths” as an arbitrary
measure of health in a population. Premature death is a theoretical concept based on the assumption that everyone ought to live at least up to the normal life expectancy for that nation and any death occurring at an age that is 10% below standard life expectancy might have been preventable. For the purposes of this report, all deaths occurring before the age of 71 were assumed to be premature deaths. It should be emphasised that this is only a theoretical concept and that every death under 71 is not necessarily preventable in real life.
The proportion of premature deaths in Gibraltar had remained stable in the past, at around 20% of all the deaths. However, in 2014 the number of persons who died before their 71st birthday rose to 56 (23.3%) and in 2015 this rose further to 59 persons (28%).
However, it has been remarked upon in several previous reports that there is usually a marked and striking gender contrast in this ‘premature deaths’ group, with only half as many women as men. In 2014 too, 16 women and 40 men died before the age of 71, and again in 2015, there were 19 women and 41 men who died early.
The number of middle-age deaths, i.e., in the 50-70 age group is another measure of comparative premature mortality that has been examined in earlier reports. Again, a large gender gap had been noticed in previous years. During the period 2011 to 2015 (inclusive), 136 men of this age group died (25.8% of all men who died), when compared with only 80 women of this age group (13.6% of all women who died). Furthermore, if only the most recent two years are taken, 2014-2015, the figures are men (37.7%) and women (12.8%). All this suggests that many more men are dying younger than women and this gap seems to be widening.
Finally, the gender differences are also seen for deaths in the older ages, i.e., over-70s. It has generally been the case that typically, male death rates begin to rise sharply from the late 50s, peak in the late 70s and fall
gradually thereafter, with very few men still left alive in the 90s. In contrast, female death rates usually do not rise until the 70s, peak in the late 80s and then fall gradually, with quite a few alive over 1000 years. This trend holds good for 2014 and 2015 as well; however, in 2015 there are two peaks for men, at 70 and 88, suggesting that men who survive the early-seventies have a very good chance of living for another ten years. All these figures seem to suggest that while people in both sexes are living longer, where the older years are concerned, the big gender gap seen in the past is becoming eroded, with women narrowly ahead.
Survival after the 90s, longevity seems to be strong in the population. In 2014, there were 50 persons who survived until the nineties (8 men and 42 women), while in 2015, there were 32 persons (6 men and 26 women) who did so. Women still substantially outlive men in this age group. Finally, in 2014, three persons died centenarians, while in 2015, just one person did.
In 2014, the leading cause of death remained Respiratory disease with 62 deaths (26% of all deaths in 2014. In 2015, Heart disease was the leading cause with 55 deaths (26% of all deaths in 2015). This is the first time in ten years that heart disease has taken the lead.
In 2014, Cancer took second place with 55 deaths (23%) and Heart Diseases came third with 44 deaths (18%), while in 2015 the positions were reversed with Respiratory Disease claiming 52 deaths (25.6%) in second place and Cancer with 45 deaths (21.7%) in third place.
These figures represent quite a contrast to the figures seen at the start of this century. In 2000, the positions of the above three causes were widely divergent, with Heart diseases leading the pack (39%) and Respiratory diseases (6%) very low down. The differences have narrowed during the past 15 years and this is illustrated in a chart in the appendix.
In recent years, deaths due to Respiratory diseases have been increasing steadily at
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about 1-2% per annum and this trend has continued in 2014 & 2015. Pneumonia is the most common cause. It should be noted that bronchopneumonia is often the terminal event in very old people and the increase in respiratory diseases may merely reflect the longevity of the population.
Although Cancer may have been overtaken as the lead cause overall, in persons under the age of 70 it remains the dominant cause of death (38.2% of all deaths in this group in 2014 and 46.7% in 2015). This proportion has also steadily increased.
Five sites, Lung, Breast, Colon, Brain and Pancreas, together accounted for nearly two thirds (60% of all cancers), with 32 deaths in 2014 and 27 in 2015. Unusually in 2015, there were no deaths from Breast cancer.
Lung Cancer remains the number one cause of cancer death, with 7 deaths in 2014 and 16 deaths in 2015. Over one in five cancer deaths (23%) is caused by Lung cancer. Unfortunately, there is currently no means of screening for lung cancer.
There is no doubt that cancer in general and lung cancer in particular are strongly associated outcomes of tobacco smoking. These public health reports have over many years, consistently campaigned for reforms to reduce tobacco consumption in the community. Tobacco is not just the most significant contributory cause of cancer, but it is directly or indirectly responsible for several other diseases. The welcome introduction of the Smoke Free Environment Act (2012) is helping to reduce the impact of passive smoking and the GHA’s Stop Smoking service continues to help smokers to give up smoking. But clearly more needs to be done to raise the cost of purchasing tobacco and reflect the actual cost of the burden on society in the price of the product.
Breast and Colorectal cancers are two examples of cancers that can be prevented by screening. Using simple medical tests, the disease can be detected when it is silent but still capable of much harm and successfully
treated. The GHA now has screening programmes in place against these diseases.
Cancer of the pancreas - which is strongly linked with long term alcohol consumption – was responsible for 5 deaths in 2014 and 2 deaths in 2015.
Other cancer sites included oesophagus, prostate, bladder, etc., in small numbers.
Infectious diseases were the cause of 9 deaths in 2014 and 8 in 2015, slightly less than that of recent years (13 in 2013 and 15 in 2012) but there is no doubt that it has been more prominent in the past few years. However, it is likely that these infectious diseases might have been terminal events of advancing age as the average age of persons dying from this cause is around 80 years (83.6 in 2014 and 78.8 in 2015) as against that of all other diseases, which tends to be below 80.
In 2014, Diabetes was listed as a contributory cause in 23 persons (10% of all deaths) in 2014 and in 20 persons (again 10%) in 2015. These figures are however unreliable as diabetes is not always recorded on death certificates and could be underestimates.
1.3 HEALTH & LIFESTYLE SURVEYThe previous GHA Report (Health Matters 2012/2013) described in detail the results of the first ever Health & Lifestyle Survey of the Gibraltar people. Following on from this success, the Minister in his Budget Speech 2014 announced the second Health & Lifestyle Survey, to take place in 2015.
The Public Health department compiled the questionnaire for the survey, which consisted of 46 questions, most of which have been externally validated.
The GHA Procurement department carried out a procurement exercise, resulting in the appointment of the local company Copywrite plc. to conduct the fieldwork for the survey in accordance with specification provided by the department. In addition, another local firm, Micro Business Systems
was appointed to provide data capture and compilation services for the survey. An experienced Information Analyst was also contracted on a consultancy basis to assist in the more complex data analysis
The Health and Lifestyle Survey was formally launched on Friday 9th January. It aimed to find out the levels of perceived health in the resident population as well as gather information on lifestyle parameters like eating, drinking, physical activity, etc. The Survey would also be able to make comparisons with the earlier Survey and examine trends. The participating public were reassured of anonymity
The questionnaires from the Health & Lifestyle Survey, containing the data collected by the door-to-door surveyors, were delivered to the department towards the end of February 2015 and analysis commenced on the 16th March 2015.
By mid-June, after about a third of the analysis had been completed, the unexpected arrival of the Census 2012 report necessitated substantial re-writing, as population counts affect practically every ratio and all the weightings for statistical interpretation.
At the time of writing, it is likely that the Survey report is expected to be published in summer 2016.
1.4 CANCER REGISTRYThe restoration of the data quality of the Cancer Registry database is continuing slowly and is likely to take some time. Currently, the Analyst is in the processing of checking that each tumour has been recorded correctly, a process that has to be done one by one manually, to detect and remove human errors, misprints, missing data etc., and is therefore time consuming.
The cleaning of the Cancer Registry is continuing, although it is a time-consuming task and the Information Analyst is gradually building local expertise based on methodology and techniques used by other countries.
It was reported in the previous GHA Report that the Gibraltar Cancer Registry had begun participating in the prestigious international CONCORD research study on global surveillance of cancer survival. In early March 2014, as part of the process, the Registry underwent a strict check of its quality of its data and responded to suggestions to improve data quality control. Towards the end of March 2014 the CONCORD study required another detailed assessment of the Registry’s potential scope and future quality, with which the Registry has complied.
In addition, the Registry also uploaded data for the European Cancer Registries network, namely ENCR Survey and a childhood cancer study questionnaire.
INFORMATION ANALYSTThe appointment of the Information Analyst has enabled research and audit of local public health feasible in a way that had never been possible before.
Two examples of the work are shown in this report, on Childhood Obesity and Dental Health.
ANALYSIS OF CHILDHOOD OBESITYIn 1998, Melanie Chipolina, the GHA Dietician carried out a survey of the body weights of Gibraltar schoolchildren and discovered that over a third of the child population was overweight or obese. In comparison, childhood obesity rates seemed higher than that of comparable populations.
It had always been the intention to revisit the question over time, but lack of resources meant that this was not possible until the appointment of an Information Analyst in 2013.
It was intended that the Analyst would compare the historic data collected in 1998 with the data currently collected by the
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school nurses annually, but it transpired that this was not possible, as the original survey pooled children of different ages, while the school nurses monitor only certain years. The Analyst also found that the classification protocols and centile charts used to define obese and overweight children in 1998 no longer existed, although this could be resolved using special software.
An attempt was made to compare the annually collected data to UK figures, but it transpired that local nurses collected data at different years. The GHA’s data collection practices were then realigned by policy to measure the children’s parameters at Reception Year and Year 6, as in the UK.
As a result of all this effort, a database is being gradually built up which should contain comparable data for analysis in the future.
ANALYSIS OF CHILD DENTAL HEALTH
IntroductionMeasuring the dental health of young
children is an important indicator of the health of the entire community. It is not only valuable as a snapshot of the baseline dental health status of the child at an early age, but it is also the period at which much of the seeds of healthy lifestyles and behaviours are sown.
“DAY AT THE DENTIST” PROGRAMMESince 2011, the GHA has run an annual GHA dental health promotion programme aimed at young children called “Day at the Dentist”, devised and led by Dr. Anthony Fearon.
The programme, which is run with the cooperation of the Department of Education, brings all children attending Year One at the First Schools in Gibraltar to visit the Dental Department in the Primary Care Centre in small groups for a day during which their dental health is measured and dental education is imparted to them in an enjoyable and engaging manner, using colourful displays, fun quizzes and interactive materials.
The programme has the following objectives:
1. To Increase access to the department2. To Provide dental education3. To Provide tooth brush, tooth paste and brushing instructions4. To Record prevalence of dental disease and help form further, more targeted dental health promotion5. To Welcome the children to a friendly environment
The Public Health department analysed the data collected by the programme during three consecutive years i.e. 2011-12, 2012-13 and 2013-14. The schools included were Loretto Convent, Governor’s Meadow, St Bernard’s, St Mary’s, Hebrew School, St Paul’s, Notre Dame and St Joseph’s First Schools.
Figure 1 shows the percentage of children in Gibraltar aged 5 with Decayed, Missing and Filled teeth by Year.
Figure 2 shows the percentage of children in Gibraltar aged 5 with Decayed, Missing and Filled teeth by School.
Figure 3 the pooled data for Gibraltar in 2011-2014 and the results for children in England, Wales, Northern Ireland and UK in 2003 as a guide.
CONCLUSIONSOverall results (DMFT) show that the dental health of Gibraltar children is similar to that of the UK and is steadily improving.
The response to the “Day at the Dentist” health promotion initiative has been very good (>88%) and stable throughout the three years. However, the proportion of children who had never visited the dentist was extremely high in Gibraltar compared to those in the UK.
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1.5 COLON CANCER SCREENING PROGRAMMEColorectal cancer (or bowel cancer) is Gibraltar’s most commonly occurring cancer (excluding skin) as well as its third most frequent cause of cancer deaths. It is also one of the world’s most rapidly rising cancers and the second most common cause of death from cancer in Europe and the United States.
Colorectal cancer is commonly a quiet disease and symptoms often manifest too late in its course and it therefore has a high mortality if untreated. However, if detected while still confined to the bowel or earlier, the disease has a good prognosis, with up to 90% surviving after treatment. There is no single simple test for colorectal cancer, but organised screening programmes are now widely accepted as the best way to reduce
the incidence of colorectal cancer.
Screening involves inviting persons over the age of 60 to submit three stool samples using specially designed kits that make taking the specimens easy and without mess. The samples are tested in the Laboratory for the presence of blood and if negative, the participant is reassured and the test is repeated every two years thereafter until the age of 74. If any time a test is positive, the participant is invited to undergo a colonoscopy, in which the surgeon inspects the inside of the bowel thoroughly to find the cause.
After three years in development, the GHA Colorectal Cancer Screening programme was formally launched by the Minister on 29th January 2014. However, certain teething problems meant that the first batches of the invitations and test kits could
only be despatched on the 31st of March but after that the programme got under way and proceeded smoothly.
The Public Health department produced a range of publicity materials to support the initiative, including a leaflet “Colon Cancer – The Facts”, another leaflet explaining the Programme, a TV infomercial promoting screening and an instructional video clip that took the participant step by step in obtaining and submitting a sample.
In April 2015, at the end of the first year, an Audit of the Colorectal Cancer Screening Programme was carried out and the following were some of the key findings:
1. In its first year, the Colorectal Cancer Screening Programme achieved its key Outcome targets of 100% cancer detection, with no false negatives.
2. The Programme picked up both the two cases of cancer that came within the screening range.
3. The current Uptake by the population is 41% against the target of 60%, based on UK experience. The reason for this low uptake is not clear, but future improvement is likely.
4. The Screening Programme had a higher than expected level of False Positives (10.6% of all tests as against 2% estimated based on UK figures). The reason for high level of False Positive results remains unanswered, but this is not due to cancer.
5. User experience has generally been positive and most problems were quickly resolved.
6. The Programme Target of 3,500 invitations per annum or approximately 300 invitations per month is only just achievable with the current resources and.
7. The Programme has a resource deficit. Even at its peak reported performance, it could meet only 77% of the annual target and forecast demand for 2016, 2018 and thereafter cannot be met with current resources. The Programme has no reserve
for contingency, for example, were the public uptake to increase to 60%, the service would be unable to cope. New strategies are required to meet the programme demand.
In summary, the Programme has been successful in achieving its objectives and has been received well. Uptake by the public is still short of the mark and resources need augmenting.
An audit of participant queries received at the Screening Office suggested that there was still come confusion about how to do the test. To address this problem, the department produced an instructional video on a DVD, which is now inserted into the mailings along with the test-kit since December 2015.
Programme activity data are in the Appendix.
1.6 ABDOMINAL AORTIC ANEURYSM SCREENING PROGRAMMEThe Abdominal Aortic Aneurysm Screening Programme was officially launched on the 25th February 2015.
The aorta, the largest blood vessel in the human body, is under constant pressure as it carries blood from the heart. In about 6-9% of older men, the wall of the aorta in the abdomen can become weak and start to expand or bulge, forming what is called an ‘abdominal aortic aneurysm’ (AAA). The condition is rare in women and younger men. Aneurysms can rupture suddenly as a catastrophic event with less than 20% surviving. If detected by AAA Screening and operated at the optimal time, survival is around 97%.
Screening involves a painless, non-invasive one-off ultrasonographic examination offered to all men around their 65th birthday. It will not need to be repeated unless an aneurysm is found. If an aneurysm is found, it is monitored by the GPs who will also offer advice on slowing the growth of the aneurysm, until surgery is indicated.
Prior to the launch date, a lot of preparatory work had to be undertaken. New screening PU
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software was developed in house with extensive testing and fine tuning. The department also produced an eight-sided information leaflet in English and Spanish. In addition, a 35-second infomercial was produced and began to be televised on GBC TV during March.
Soon after the Abdominal Aortic Aneurysm Screening Programme was publically launched, twelve persons who were beyond the upper age limit (over 60 years) requested to take part in this initiative and were added to the Programme using the current protocols.
By the end of the year 2015, a total of 197 men had been screened. The programme detected two small aneurysms, two medium sized aneurysms and one large aneurysm. A large aneurysm is at high risk and warrants early referral to a specialist vascular surgery centre, which was promptly arranged by the GHA. The other persons with aneurysms will be kept under close surveillance.
1.7 INFECTIOUS DISEASES
Laboratory confirmed infectionsThe average number of Laboratory confirmed cases of infection has been around 240 for the last ten years. The number dropped in 2013 to 217 cases, and then fell to 201 in 2014. It rose slightly to 219 cases in 2015.
Food-borne infectionsIt is a public health success story that numbers of cases of food-borne infections continue to decline over the years.
Compared against totals that averaged around 90 per annum in the early 2000s, the numbers of Salmonella infections have dropped sharply (only 10 cases in 2014 and 16 in 2015). Salmonella infections dramatically reduced following the campaigns in the mid-2000s to encourage the use of British industry standard Lion-marked eggs sourced from vaccinated chickens, together with greater public awareness of safe cooking of poultry and shellfish.
Campylobacter infections used to average about 60 cases a year in the past, falling to about 45 per year in the last few years, before starting to rise slightly again (50 cases in 2014 and 46 in 2015). Campylobacter infections are spread through undercooked meats, contaminated foods and unhygienic contact with pets. Its decline was accompanied by strong public health education campaigns of the mid 2000s on improved kitchen hygiene, avoidance of raw milk consumption and the proper cooking of meats and poultry. More recently, there has been publicity regarding widespread campylobacter contamination of meat carcasses, which may be why the infections are resurging slightly and more education may be necessary.
Ebola outbreak in West AfricaOn 23rd March 2014, the WHO confirmed an outbreak of Ebola virus disease in south-eastern Guinea. Ebola is a virus that causes haemorrhagic fever, is spread by simple contact and carries a high mortality. This was the first time that an outbreak has been found in this part of Africa and rapidly spread to neighbouring countries, like Liberia and Sierra Leone, soon becoming the largest known outbreak of this disease.
International travel in the 21st century no longer makes it possible to ignore distant disease outbreaks as unlikely threats. The Public Health department commenced the task of building up local preparedness as a response to the threat posed by the importation of Ebola Virus into Gibraltar.
In early August, when the risk became tangible in the international context, Gibraltar’s Port protocols were strengthened with specific surveillance measures applied to ships or persons having visited affected areas. The Borders and Coastguard Agency, Pier Masters, HM Customs, the Airport and the Police were all issued with protocols.
A comprehensive Viral Haemorrhagic Fevers Policy document covering preparedness, disease recognition, personal protection, infection control, investigation, clinical management, specialist advice and waste
disposal was prepared. A dedicated reception and isolation unit was created within the Hospital for admitting potential suspect cases swiftly and safely. The GHA procured stocks of the recommended personal protection equipment for infection prevention (gowns, masks, etc.), together with the policies for their usage.
All doctors in Gibraltar were issued with guidance to identify persons who had fever, who had visited affected areas or who had been in direct contact with an infected person. This response was actually invoked on three occasions, but other common illnesses like malaria and bowel inflammation turned out to be the causes.
The GHA also conducted two separate exercises to test the Ebola response protocols in November and December 2014. The Exercises simulated a patient in the Emergency department returning from Liberia and being transferred to the Isolation Unit. The Exercises were successful, with many processes working as planned and with a few learning points as well.
However, given that the greatest risk to European nations arose from the repatriation of contaminated or infected aid workers, international protocols were developed for this eventuality.
A programme of training was instituted for all key staff, with the Infection Control Practitioners offering weekly sessions on the donning and doffing of Personal Protective suits. Training was also given to officers of the Port, the Environmental Agency, the Police, the Coastguard and the Rescue services.
By September 2015, the threat had passed and the dedicated facilities were stood down.
Swine Flu InfluenzaThe novel H1N1v virus arrived in 2009 and was dubbed the “swine flu” virus. Since then, it has taken over from the regular human virus and is now the world’s dominant influenza strain. It generally causes a milder form of influenza than the human virus, but
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in a few people, it can cause catastrophic and even fatal disease. Pregnant women and people with certain pre-existing diseases are at particular risk.
Early in 2014, two serious cases of H1N1v influenza A were reported. A young pregnant woman (who had not been vaccinated) and an older woman were both admitted simultaneously to the Critical Care Unit with acute respiratory distress. Fortunately both women made a satisfactory recovery and subsequently, the pregnant woman delivered a healthy baby. Vaccination can prevent swine flu and the campaign to vaccinate pregnant women was stepped up once again.
In late 2015, a case of H1N1v was reported in a middle-aged man, whose condition deteriorated rapidly, necessitating critical care, but he recovered fully. Family (household) contacts were contacted and offered vaccination. Soon after, a second case of H1N1v occurred in an older woman who developed acute respiratory distress syndrome. Household contacts were contacted and offered vaccination, while some staff contacts and other family contacts also received medical prophylaxis.
The annual seasonal flu vaccination campaign was started. In the GHA, staff and all long stay patients in both the GHA, Cochrane and Calpe wards were offered vaccination. To date 392 persons, both patients and staff had been vaccinated by the Infection Control Practitioners.
Norovirus outbreaksIn the first week of April 2014, an outbreak of vomiting and diarrhoea occurred in Mount Alvernia, affecting all floors and 17 residents. Infection control precautions were instigated and floor isolated and one worker was sent home. Despite immediate measures the outbreak spread to the other floors and precautionary measures were applied. Floors were closed for 48 hours to visitors whilst the outbreak was at its peak. All stool specimens collected and tested were found to be negative for routine pathogens, Clostridium difficile and Norovirus, but
clinically the diagnosis was presumed to be a type of Norwalk virus. As is usually the case, the outbreak was self-limiting and all those affected recovered without any ill effects.
In early August, a small outbreak of Norovirus diarrhoea and vomiting occurred in Mount Alvernia. All infection control measures where instigated promptly by the lead nurse and this did not spread to other floors.
Cluster of Clostridium difficileClostridium difficile is a bacterium that is capable of causing disease, but often lives harmlessly in the intestines of many people, because it is kept in check by the normal flora of the human gut. Sometimes however, typically after the person has taken a lot of powerful antibiotics which have cleared the intestines of most other organisms, clostridium difficile may become dominant, causing a severe diarrhoea which may be bloody, resulting in damage to the colon and even death. The bacterium is also contagious and can spread through contact or contamination.
In July and August, seven hospital patients were found to have Clostridium difficile infection, but at different locations and dates. Detailed investigation did not point to cross infection as the cause and this was proved when samples showed slight differences in bacterial types. Nevertheless, all healthcare workers were advised to increase hand washing precautions and use protective clothing. Contact precautions and waste disposal practices were closely monitored. Doctors were advised by the consultant microbiologist to use antibiotics prudently.
ScabiesIn early 2015, St Martin’s School notified that a child had been diagnosed with Scabies. The child was reviewed by the dermatology specialist nurse, who confirmed the diagnosis and advised that all direct contacts should be treated. Approximately 16 people were given simultaneous treatment in line with good practice guidelines. Education and information was provided to staff at St
Martins and Tangier Views as well as to parents of the affected children. The case was quickly controlled and no further spread was observed.
World Hand Hygiene Day (5th May 2015)Handwashing is a critical skill for the prevention of infection and of any onward transmission to patients and others.
The World Hand Hygiene Day is an event promoted by the World Health Organisation. The Infection Control Practitioner and the Health Promotion Officer jointly arranged an event at the Primary Care Centre, alongside similar events all over the world.
On the day, Infection Control Nurses organised the following events:
• spot checks of staff hand hygiene on wards
• photos of staff taken with the #SAFE HANDS# badge and uploaded to the WHO website.
• Local public awareness campaign on social media and the GHA website.
GHA staff members and the public were encouraged to participate and test their handwashing skills at this event, by subjecting their washed hands an ultraviolet scanning device that can detect improperly washed areas. While the results were reassuring in that the hands of trained professionals consistently bettered that of the untrained public, some professionals were also chagrined to find parts of their hands to be shown to be incompletely washed. Proper hand washing techniques were demonstrated as part of staff training.
The event was covered by GBC and the Gibraltar Chronicle. This was a successful campaign and well received by all participants.
Environmental auditsInfection prevention is an endeavour that demands constant vigilance, which the two Infection Control Practitioners undertake.
In 2015, the Infection Control Practitioners carried out audits of the clinical and non-clinical environments in GHA premises for evidence of infectious hazards. The premises included the A&E unit, Dudley Toomey ward, Victoria ward, John ward, Captain Murchison ward and the Critical Care unit. The audits also inspected cannula care and catheter care on the wards. The audits uncovered areas of bad practice as well as of good practice.
Reports of findings were subsequently sent to ward and line managers and a presentation was made to the GHA Executive.
Other infectious disease matters• Two cases were reported in March of tuberculosis, one a local resident and the other a man of no fixed abode. Both were commenced on anti-tuberculosis treatment. Family contacts were traced where possible and advised appropriately.
• An unusual cluster of six Pertussis cases occurred in 3 adult couples during October. Cases were unrelated and not known to each other. All were treated with antibiotics.
• Over the years, Gibraltar has been relatively fortunate not to have encountered too many of cases of antibiotic resistance. However, in 2015, a patient on kidney dialysis was found to have infection by a bacterium that was resistant to the powerful high level antibiotic Vancomycin. The patient was immediately isolated and specific precautions were introduced to prevent spread of the bacterium. Relevant departments (Critical Care Unit, Dialysis Unit & the Domestic services) were given advice and deep cleaning of premises was instituted after the patient left. After intensive efforts, negative test results were reported and it was concluded that the bacterium had been successfully eradicated.
• In August 2015, six local children who had attended a Scout Jamboree in Japan were put on alert following cases of meningitis reported there. However, the event passed without incident.
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1.8 HEALTH IMPROVEMENTThis section is currently run by one Health Promotion Officer, Mrs. Daya Dewfall, who has a wide portfolio of duties in the health education of the general public, as well as in supporting health care professionals to deliver better health. Towards the end of 2015, a second Health Promotion Officer was recruited and will be joining the department in early 2016
The Health Promotion department is a busy one. The following are some of the activities carried out within the department.
CAMPAIGN EVENTS
Breastfeeding The Breast feeding Awareness Day took place at Mothercare on 29th May 2014. This is an important event and the Department freed up its clerical officer to support the Health Promotion Officer on the day. Media coverage was organised for the event and a number of resources prepared.
The Health Promotion Officer also joined with local Breastfeeding support charities at the ’Big Latch On’ events at Casemates on 2nd August 2014 and 1st August 2015 to promote breastfeeding.
Sun AwarenessThe GHA held a Skin Cancer Screening Day on 26th April 2014. The Health Promotion Officer supported the event by organising a display for the day in front of the ICC building, multiple displays within the Primary Care Centre and media coverage for the event.
The Health Promotion Officer and the Dermatology Nurse co-organised a Sun Awareness event for the Brownies (5TH Group) at their premises in Varyl Begg Estate. The Brownies were grouped into three teams and asked to design a poster on sun safety using cut-outs from magazines, posters and colouring pencils/felt tips- the posters designed were displayed within the Primary Care Centre.
The Department produced an infomercial for the GBC on sun safety and broadcast it on GBC TV from August 2014.
No Smoking Day 2014/2015The Public Health department organised a campaign event for No Smoking Day on Wednesday 12th March 2014 outside the ICC Building on Casemates Square between 9:00 AM and 3:30 PM.
Staff created a display comprising of an assortment of posters on the effects of smoking on health. Posters were displayed and several leaflets were available for distribution to the public. An eye-opener for those who have not seen them before and still a favourite for those who have, are the props that include a model of lungs damaged by smoking and a display unit containing several jars of chemicals, illustrating just a few of the over 600 chemicals that are present in tobacco smoke.
Members of the public, including several school children were given information on the ill-effects of smoking and the support available from the GHA to quit smoking. A GHA Nurse Practitioner carried out Carbon monoxide testing on some smokers to reveal to them the invisible poisons already in their system.
World Blood Donor Day 2014World Blood Donor Day was held on 13th June 2014 at Casemates. The event was organised by the Department and supported by Blood Bank nurses, the Police, Customs and the Fire & Rescue services. The public showed keen interest in the event and several individuals registered themselves as potential donors.
World Asthma Day 2014/2015A radio talk was arranged on Radio Gibraltar’s Health File programme for World Asthma Day (May 6th), with Nurse Practitioner Elizabeth Borges interviewed at the Primary Care Centre. An Asthma awareness event was organised during 2015. This included a workshop on the correct
use of inhalers prescribed for asthma and respiratory conditions.
Dental Health Awareness Day 2014A Dental Health Awareness Day event was held on Thursday 18th September to highlight the importance of adequate oral hygiene and dental care. The Health Promotion Department mounted a display outside the ICC Building. GHA Dental Health staff and Health Promotion staff were in attendance. The event was covered by local media and was well received by the public especially parents of young children.
The Public Health department also supported the ‘Day at the Dentist’ campaign, which is aimed at small children, by supplying toothbrushes for the campaign.
Sun Awareness, Sun Safety and Skin CancerSun awareness was promoted at the Gibraltar Music Festival on 6th September, with free sunscreen (provided by the Ministry of Culture) being distributed to all at the event.
An infomercial was produced and broadcast to highlight the dangers of sun exposure, featuring Ms Wendy Clouter, who is a prominent local campaigner in this field and a malignant melanoma survivor. The infomercial was relayed on GBC TV during August and September 2014.
Noise Induced Hearing Loss CampaignThe Health Promotion Officer teamed up with staff from the Ministry of Equality & Culture and the registered Charity GHITA [Gibraltar Hearing Impairment and Tinnitus association] to hold an awareness day for Noise induced hearing loss on 24th July 2014. A display was mounted and the event was covered by GBC and the Gibraltar Chronicle. Leaflets and disposable ear plugs were distributed to the public.
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Dementia Awareness Day 2014The Health Promotion Officer participated in the Dementia Awareness Day held on Saturday 21st September 2014. Also in attendance were staff from the Care Agency, Occupational Health and the Dementia and Alzheimer’s Support Group.
World Mental Health Day 2014The department organised a ‘Mental Health’ Awareness campaign on 10th October with the support of staff from the GHA mental health facility and the Psychological Support Group.
The Health Promotion Officer set up a mental health awareness exhibition at John Mackintosh Hall from 6th-10th October. This culminated in World Mental Health Day on Friday 10th October. The event was supported by professionals from the mental health team, psychological support group and club house Gibraltar. An article on mental health and mental well-being was written by the Health Promotion Officer for the Gibraltar Chronicle and featured on the 10th of October.
World Diabetes Day 2014/2015World Diabetes Day was held jointly with Diabetes team on 14th November 2014. A pitch was set up in the foyer of the ICC Building to raise public awareness about diabetes and about the education programmes offered by the GHA. The department produced and displayed a banner to promote the new diabetes programme ‘Walking Away from Type 2 Diabetes’. There were also opportunities for individuals to calculate their Diabetes risk score and a nurse present to educate the public on the importance of prevention in relation to Diabetes, such as good foot care.
An infomercial was developed with the Diabetes Specialist Nurse to create awareness of the disease as well as the GHA services available, such as DESMOND and the ‘Walking away from Diabetes’ programmes.
World Aids Day 2014/2015The Health Promotion Officer and the Infection Control Team mounted a display in the foyer of the ICC Building on Monday 1st December along with the ‘Friends for Life group. Red ribbons were handed out. Several posters and leaflets were displayed. The event was covered by GBC TV and Gibraltar Chronicle. A write-up was uploaded to the GHA Facebook page.
No Smoking Day 2015The Health Promotion Officer and a Nurse Practitioner conducted the annual No Smoking Day (NSD) campaign on Thursday 12th March 2015 outside the ICC Building. Several new displays acquired by the department were mounted for public viewing. Once again, smokers were given the opportunity to use a Carbon Monoxide monitor to check the levels of toxic Carbon Monoxide gas that was coming out of their breath, even a while after they had smoked, and once again it proved popular. This is a powerful tool that is used regularly in the smoke cessation clinics – it often shocks, but sends a clear message that is difficult to ignore. The event was covered by the media.
A new smoking infomercial on passive smoking has been produced by the department and is due to be televised in the next few months.
Change for Life‘Change 4 Life’ is a holistic health promotion initiative that has been implemented nationwide in the UK for a while now. It is led by the UK Department of Health and brings together professionals from the health, education and leisure sectors with the unified aim of improving children’s diets and levels of activity so as to reduce the threat of developing preventable chronic diseases such as diabetes, heart disease, hypertension and others.
Research indicates that people are more likely to alter their behaviour if they believe that everyone around them is doing the
same. Change 4 Life therefore aims to inspire a society-wide movement that encourages everyone to make changes to their diet and activity levels in an attempt to tackle obesity.
On 9th January 2015, the GHA launched the Gibraltar Change 4 Life promotional programme, led by the Public Health department, to encourage a new way of thinking in regard to diet and lifestyle. As part of the launch, four new leaflets were produced by the department for distribution within all local schools, titled:
1. Ensure your Child has a Healthy Breakfast
2. Getting the Balance Right
3. Fun Snacks for Healthy Kids
4. Balancing the Packed Lunch
One thousand copies of each leaflet were officially handed over to the Director of Education at a Press Event on the same day.
The department also designed and produced a new infomercial for the Change 4 Life initiative and broadcast this on GBC during the month of February. The infomercial alerts parents to the high levels of sugar that 4-8 year olds regularly and unknowingly consume.
Although the Change 4 Life programme is initially and intensively aimed at children, the target audience for the messages it conveys at the broadest level, is every individual in Gibraltar.
Heart Health Awareness Day 2015An awareness event to highlight the importance of heart health was held on Friday 13th February 2015 outside the ICC Building in conjunction with the Cardiac Rehabilitation Nurse. Members of the Gibraltar Sports & Leisure Authority (GSLA) and of the Physical Activities Association for Mature Older Adults (PAAMOA) also attended for a brief period. The event was well received by the public and was covered by the local media.
Ocean Views openingThe new mental health facility ‘Ocean Views’ was officially inaugurated at a public event on March 16th 2015. The Public Health department procured promotional pens with the Ocean Views motif and these were handed out at the event.
‘The Well Child’A public awareness event titled ‘The Well Child’ was held on Friday 17th April 2015 at the atrium of the ICC Building to showcase the work of the Child Health team of the GHA in promoting the health of Gibraltar’s youngest citizens and their numerous accompanying services such as immunisation clinics, school visits, monitoring of growth, etc., that contribute to the successful development of young people through infancy, childhood and adolescence.
This group of GHA staff rarely appears in the limelight, but their work is vital to the community.
An array of informative posters was displayed and leaflets were tabled, with as many staff as possible in attendance to meet with the public and address their questions. A large banner-style poster was on view, depicting a collage of the work of the Team, specially designed by local designer Niche Creative Solutions for the event. Younger visitors attending the event received balloons, while those arriving in prams received bibs with the GHA Well Child logo.
The event was well covered by the media. The Chief Minister Mr Picardo and the Minister for Health Dr Cortes attended the event.
A series of articles describing the work of the Child Health team and the wide range of services they provide was also published in the Gibraltar Chronicle in the lead up to the event.
Sun AwarenessThe popular annual GHA Skin Cancer Screening event took place on Saturday 25th
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April 2015 at the Primary Care Centre, in partnership with the Clinical Manager and staff of the dermatology section. The Health Promotion Officer helped to organise the event and supported it with posters and leaflets, designed and procured for the event.
The Health Promotion Officer worked with the Lifeguards to promote sun safety awareness at the beaches for the forthcoming summer season.
The Health Promotion Officer worked with the Department of the Environment and Climate Change with the aim of erecting public message boards depicting the message
‘Prolonged Exposure to Solar Radiation is harmful BE SUN SMART! - Protect Yourself’.
Mental Health Week 2015The Mental Health Week event was held from 11th to 15th May 2015 at the John Mackintosh Hall.
The department sponsored the printing of a Poster designed by the young people with the objective of de-stigmatising and promoting a better understanding of mental health. The Poster was used as a backdrop during the event.
The Health Promotion Officer supported the week’s events and also a follow-up fund-raising event on Saturday 31st May.
Crohn’s Disease Day 2015The department met with representatives of a local support group for Crohn’s Disease to discuss the need for more public awareness on the disease and on inflammatory bowel disorders in general. A charity was launched publicly on 7th May 2015 under the name Crohn’s Colitis Gibraltar in readiness for World Crohn’s Disease Day on 19th May.
Hand Hygiene Day - 2015The department produced a number of posters on World Hand Hygiene Day, 5th May 2015 to support the Infection Control Nurses in the WHO ‘Saving Lives’ campaign,
• The Health Promotion Officer participated at a conference on Health and Safety in the Workplace at John Mackintosh Hall. The presentation included dangers of sun exposure, skin cancer and ‘the patient’s experience’
• The HPO supported the annual Citizen’s Advice Bureau event at the Piazza on Thursday 3rd December, handing out “Brighten your Christmas with Advice” leaflets.
SCHOOL TUCK SHOPS NEED TO CHANGEThe Public Health department is leading a campaign to tackle the growing problem of obesity in children and the gathering risk of diabetes in future generations, calling for long overdue reform of school tuck shops.
At heart is the problem that School Tuck Shops (which are Government supported) sell unhealthy food items to schoolchildren, including high sugar products like chocolates, cakes, biscuits and high calorie drinks. For example, a single 380 ml bottle of Lucozade contains 10 teaspoonfuls of sugar. Despite several appeals and campaigns from health professionals and promotional efforts from suppliers like Gib-Maroc, the School Tuck Shops are resistant to replacing stock with fruits, salads and similar healthy products, citing commercial reasons.
The Public Health view is that Government should not sponsor the marketing of poor health to schoolchildren, effectively counteracting health education programmes to encourage healthy eating habits in children. Furthermore, the school tuck shops are able to do so from a privileged position, right on school premises with no direct competition or incentive to change. Their presence also creates disincentives for parents to send healthy packed lunches and acts as a distraction for children.
GHA professionals have long campaigned that the Government supported school tuck shops should switch to supplying
healthy products to children, failing which they should be closed. The Public Health department has offered alternative resources that could potentially be introduced in schools following a pilot study in one school.
The matter needs urgent resolution.
ANTIBIOTIC AWARENESS WEEK
A high profile campaign was led by the Public Health department through the European Antibiotic Awareness Week (15th-21st November 2015) to promote the awareness of antibiotics as a vital life-saving resource, but also one open to risk of misuse and the long term threat to humanity.
The campaign included a number of initiatives with participation from across the GHA:
• On Antibiotic Awareness Day (18th November 2015) a stall was manned outside the ICC Building foyer by GHA staff from Microbiology, Health Promotion, Pharmacy and Infection Control displaying posters and information leaflets to raise public awareness about antibiotic resistance and the importance of correct antibiotic use. Leaflets were distributed to the public and advice regarding antibiotic usage given. The event was covered by GBC TV and radio.
• A series of articles by different professionals were published in the Gibraltar Chronicle throughout the week, covering different aspects of antibiotic use, misuse, antimicrobial resistance, prevention of disease and control of infection in hospital.
• The Gibraltar Chronicle published an interview with Dr Nick Cortes, Consultant Microbiologist.
• The GHA launched comprehensive evidence-based guidelines on antibiotic usage by staff.
• A number of retail pharmacies (Morrisons, Trafalgar, Wesley and the GHA pharmacy) participated in the event as ‘drop off points’ for the disposal of unused/unwanted antibiotics
which promotes hand hygiene. Stickers with the Clean Hands logo were also procured for use by GHA staff working within clinical settings on the day
World Diabetes Day 2015 Members of the GHA Diabetes team and the GHA Dietetics department joined the Health Promotion Officer in a campaign on Friday 13th November held outside the ICC Building.
World AIDS Day 2015The event was observed on 1st December 2015 with a display outside the ICC Building that included posters and leaflets on HIV and
Mental Health Promotion in SchoolsMental Health Promotion in Schools
The Health Promotion Officer set up a Mental Health Information Stall at Bayside Comprehensive School on Friday 9th October 2015. Several leaflets and posters were displayed and the stand was well received by both teachers and students. Other professionals included staff from Club House, Gibraltar, Mental health, Practice Development (GHA) and Youth services.
Other Events• The Health Promotion Officer met with professionals from the Care Agency, the Ministry of Equality and Mental Health professionals to discuss a future awareness event is schools with regard to Eating Disorders.
• The Health Promotion Officer supported the Autism Awareness event organised by the Department of Equality at the Piazza on 2nd April 2014.
• The HPO supported an awareness event on Stroke organised by John Sheppard and held on Saturday 7th November outside the ICC Building.
• The Health Promotion Officer participated in the World Alzheimer’s Day event at the Convent on 21st September 2015.
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and other oral medication antibiotics by the public. Collection points were also located at the Primary Care Centre.
• At the event, the public were encouraged
to take part in a small quiz on antibiotics
• 87% knew antibiotics were used for treating bacterial infections
• 13% thought antibiotics killed viruses.
• 10% thought antibiotic resistance was out of control.
Resources Production and Distribution
• A display of resources on the Colon Cancer Screening Programme was laid out for representatives of the Moroccan Community, who were invited to view and discuss further resources needs.
• The Department produced a series of four leaflets on Healthy Eating for children of school age which were distributed to schoolchildren in the new school term in September 2014.
• The department procured Leaflets based on the UK ‘Change for Life’ programme on healthy eating, aimed at schoolchildren.
• The department procured Dental packs ‘Tooth time’, and distributed these to preschool children.
• An educational resource DVD for the DESMOND diabetes self-care programme has been procured from the UK and is being modified to cater to local population.
• The Dental Health department was supplied with an educational resource, showing the effect of sugar on teeth, for use at the regular teaching sessions.
• Health promotion posters and leaflets were supplied to St Bernadette’s Resource Centre.
• Display units were provided to the Maternity department to facilitate display of health promotional material.
• Leaflets and posters on the dangers of smoking were given to the Royal Gibraltar Police, to address their concerns about smoking in the workforce.
• Following a recent incident involving infestation with scabies, the GHA leaflet on Scabies was redesigned and distributed.
• A new leaflet for the Meningitis B vaccine was designed and printed. This is being distributed primarily through the Maternity and Child Health Departments
• A DVD containing the instructions for the Colorectal Cancer Screening programme for distribution to clients was completed in December 2015.
• A new poster was designed for the Colorectal Cancer Screening Programme and displayed at St Bernard’s Hospital (Outpatients and Medical Investigation) and the Primary Care Centre . It is planned that the poster also be displayed at other locations, like senior citizens clubs and the Victoria stadium.
• A leaflet on Intermittent Bowel Disorders with approved health content was compiled and professionally designed for the Crohn’s Disease support group.
Engagement with the Media
RadioThe Health Promotion Officer delivered on Radio Gibraltar’s “Health File” programme on the following topics:
• Bug Busting (Head lice removal)
• Smoking in cars
• Preparing for the Flu
• HIV and AIDS
• Heart Health
• Salt
• Blood Donation
• Spring Allergies
• Diabetes
• Antibiotic awareness press
PressThe following articles were published in the Gibraltar Chronicle and local magazines:
• A stress-free Christmas
• Abdominal Aortic Aneurysms
• Antibiotics
• Bug-Busting
• Change 4 Life
• Colon Cancer
• Common Winter Illnesses
• Diabetes (series)
• Drink Safe and be safe this Christmas
• European Antibiotic Awareness Day.
• Flu facts
• Influenza
• Inter-Island Public Health Forum conference in Guernsey
• Look after your Heart (7 part series).
• Looking after your eyes
• New Year, New You.
• Pregnancy and the Flu
• Safe Hands provide clean care
• Shingles
• Smoking
• Spring Allergies
• Stopping Smoking
• Summer Health
• Sun Safety
• Winter Health (5 part series)
• Work of the Child Health department, (4 part series)
• World Blood Donor Day
• World Health Day.
• World No Tobacco Day
• You can control your asthma
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InfomercialsInfomercials are short video clips produced for broadcast on local television and media and containing health educational messages. They have proved popular and ideas for new infomercials are regularly under discussion with the designers.
• An infomercial on Diabetes was produced by the department and was relayed from April 2015 on GBC television. It aims to show the range of serious complications that can accompany this disease and the importance of early detection.
• An infomercial on Colorectal Cancer Screening was broadcast on GBC TV during June.
• A new infomercial has been commissioned on Alzheimer’s disease and Dementia to promote public awareness of this insidious and distressing illness, together with publicity about the support that families and carers can get. A new poster and some flyers have also been designed. The infomercial is to be broadcast in January.
• A new infomercial is being commissioned on Depression.
• An infomercial on Antibiotic resistance is under preparation.
Support for Community Education
• The department continues with its core task of procuring and supplying educational resources (leaflets, posters, etc.) for GHA use. However, from time to time, it also supplied educational materials to some private premises such as aon insurance and Natwest Bank upon request.
• The Health Promotion Officer met with members of the Police, Care Agency and the Crime Prevention unit to discuss alcohol awareness and binge drinking amongst school children.
• The Health Promotion website, which was created in 2003, has been undergoing
a redesign. Apart from the need to update obsolete information, there is a growing need for information in the community and the demand for more public engagement. It is currently planned that the redeveloped website will be ready for launch in late spring of 2016. It will in future operate under a new domain called yourhealth.gi to make it more appealing to younger users.
1.9 AIRFIELD INCIDENT EXERCISE 2015The GHA participated in an Airfield Incident exercise organised by the Royal Gibraltar Police and with all emergency services participating. These exercises take place every two years, but this Exercise had two additional objectives in to the usual main aims – it was intended to test the new Airfield Incident Plan completed in December 2014 and to test the new Silver Command vehicle acquired in October 2014.
The Exercise took place on the afternoon of 18th March 2015, simulating the crash of a commercial airliner, resulting in around 30 casualties. The Exercise Emergency teams from the GHA’s Emergency Department were rapidly deployed to the incident site and took charge of the casualty triaging and clearing procedures.
The GHA Ambulance service successfully carried out operations in evacuating all the casualties, while the St. Bernard’s Hospital Emergency Department played its part in receiving and “managing” the casualties.
The Exercise also provided the opportunity for GHA senior managers to test their command and control of the incident from the “Majax Room” set up in the Board Room of St. Bernard’s Hospital.
In general, the Exercise went off very well and was widely acknowledged to be a huge improvement over the relatively indifferent response performance of past years. It appears that there is a greater understanding of how the Plans are meant to work and of individual roles. It was however noted that some areas like activation procedures and facilities at the
incident site could be improved.
A report of the GHA’s experience and lessons learnt from the Exercise has been sent to the Government’s Civil Contingency Committee.
1.10 IIPHF CONFERENCE 2015The Director of Public Health led a delegation of four GHA staff to represent Gibraltar at the Conference of the Inter Island Public Health Forum, which was held at Guernsey during 10th to 12th June 2015. The Forum is a meeting point for public health practitioners of all types who are united by their working in small territories and has been in existence for over 20 years. Gibraltar hosted the 2000 and 2008 meetings of the Forum.
The Gibraltar delegates were the Director of Public Health, one Health Promotion Officer, one Information Analyst and one Infection Control Nurse, all of whom made presentations.
• The Information Analyst gave an account of the findings of Gibraltar’s 2008 Health & Lifestyle survey and the lessons arising from its findings as well as international comparisons.
• The Health Promotion Officer presented Gibraltar’s experience with Infomercials, at which several clips of infomercials currently broadcast on GBC were shown. Being usually expensive to produce, infomercials are not common practice in small territories and several delegates expressed surprise and admiration at Gibraltar’s achievement. Many asked if they could collaborate on future ventures.
• The Infection Control Nurse described an audit of the hospital environment and how the act of drawing attention followed by education can lead to sustained improvements.
• The Director of Public Health reviewed the evolution of the Forum’s website, ending with the undertaking by Gibraltar to manage the website on behalf of all territories.
Gibraltar delegates also presented posters on the “Well Child” and “Preparing for Ebola”.
The event was covered by local media. The Director of Public Health gave a press interview to Guernsey Press and also spoke on BBC Radio Guernsey, describing Gibraltar’s contribution to the work of the Forum.
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2. PUBLIC ANALYST
The Public Analyst is responsible for providing an extensive range of services to the Government of Gibraltar, Gibraltar Health Authority, Environmental Agency, Social Services, Royal Gibraltar Police (RGP), Gibraltar Defence Police (GDP)., HM Customs, HM Prison, Ministry of Defence (UK) and local private companies.
The Food and Drugs Act (1964) (Act. No. 1964-07), Part III – Administration, Enforcement and Legal Proceedings. Section 32, requires the Public Analyst to perform the statutory function of microbiological and chemical examination and analysis of food and drink to ensure the health and safety of the public in relation to food standards, consumer protection and environmental matters such as water samples from our beaches.
Under the Drugs Misuse Act and Crimes Act 2011, the Public Analyst is responsible for providing a wide range of scientific analysis including analysis of drugs of abuse, screening for drugs of abuse, toxicology analysis in post mortem cases, as well as providing expert witness to the law courts.
During early 2014 the Thermo Scientific Gallery was introduced at the Laboratory of the Public Analyst (LPA) as part of its programme to automate and update methodologies and practices. This instrument, which is fully automated, is used to determine the water quality by biochemical analysis. It allows for the simultaneous determination of a number of chemicals from a single sample and at present can analyse up to eight different individual chemicals. In order to increase the chemical analysis capabilities a manual method using the HACH DR 3900 spectral photometer was also introduced to cover an extra nine chemicals not presently available with the Gallery plus alternative methods to that undertaken by the automated Gallery.
During 2014 and 2015 a total of 48 water samples were tested for Legionella pneumophila an increase of 182% from 2012 and 2013. Both L pneumophila serogroup 1 and L. pneumophila group 2-15 were isolated in 10 of these samples. L pneumophila is the most common cause of Legionnaire’s Disease.
The increase in the Legionella investigations
is partly attributed to the regular analysis of water samples from the water tanks for Commonwealth Park’s pond and fountain although Legionella has not been isolated from these samples. Samples for general microbiology were also received from these tanks has also been introduced as part of the surveillance programme.
The number of potable water samples submitted by the Environmental Agency, GHA, AquaGib and the Ministry of Defense for chemical and microbiological quality in 2014 and 2015 were very similar to those of the previous two years. The milk and mineral water for samples submitted by the Environmental Agency as part of the importation programme however increased by 235% from the previous year.
The number of seawater samples received by the LPA increased by 101% from the previous two years. The deterioration in the microbiological quality of seawater from Western Beach continued, slightly improving during the summer season but then markedly deteriorated at the end of the summer and the rest of the year. As a result of this the seawater from Western Beach remained analyzed three times a week (outside the bathing season) throughout the whole year as were weekly samples from the other beaches (even though EU regulations state no fewer than 4 samples need to be taken and analyzed per bathing season). The introduction of the” Environment (Quality of Bathing Water) Regulations 2009” in July 2015 reduced the parameters from 3 to 2 as to the indicators organisms to be detected.
Screening for drugs of abuse in urine increased by 48%, with both the Care Agency and HM Prison having increased their detection programme. The seizure of a large number of bales of cannabis resin in several operations by both the Royal Gibraltar Police and Gibraltar Defence Police required the Public Analyst to weigh and analyze these to be used as evidence for prosecution in court. The number of substances (drugs) for identification which required analyzing by the Public Analyst increased by 8.3% during this period.
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3. DIABETES SERVICES
The Adult Diabetes Service provides care for people from age 18 years upwards
There are daily clinics at St Bernard’s Hospital and clinics Monday, Tuesday, Thursday and Friday at the Primary Care Centre. The team provides occasional outreach support to Ocean Views, the Prison and Elderly Residential Services.
The clinics cater for people with established and newly diagnosed Type 1 and Type 2 diabetes. People are invited for Annual Reviews to ensure their diabetes is well managed and the department also see people with acute problems, for insulin initiation sessions, patient education and psychological support. The team holds weekly review clinics for women with Gestational diabetes and works with midwives and Obstetricians regularly to support women with diabetes in pregnancy.
The team provides ward visits for hospitalised patients and advises on all aspects of their diabetes care and provide follow up appointments after discharge. An average of 155 people are seen per week in the clinics and on the wards at St Bernard’s Hospital.
In addition to these clinics the team provide structured education sessions for people with Type 2 diabetes (DESMOND), as well as sessions for people at risk of developing diabetes to reduce their risk factors (Walking Away from Diabetes).
The team also provide 1:1 education for people with Type 1 diabetes and group sessions for people with Type 1 in preparation for Insulin Pump Therapy.
The team supports the School of Health Studies by providing Diabetes education to student nurses, enrolled nurses and qualified nurses and also provides expertise in diabetes management to GPs, Consultants and Hospital doctors.
Part of their role is to work with the Health Promotion team to deliver several Diabetes Awareness events each year and contribute to articles in local newspapers and magazines about diabetes issues.
The adult diabetes service is provided by
Susan Edwards (mainly at the Primary Care Centre) and Julie Parker (mainly at St Bernard’s Hospital).
2015 saw the introduction of regular Diabetes continuous professional development meetings with multi- disciplinary team (MDT) colleagues and GPs in an attempt to improve the services on offer and the skills and knowledge of the MDT members.
Dr Lorenc, Consultant Endocrinologist also commenced a weekly dedicated diabetes clinic to review all people with Type 1 diabetes annually and more complex clinical cases of people with Type 2 diabetes.
The diabetes service is supported by an administrator at the Primary Care Centre who organises the appointments and annual review clinics. It relies on the professional support of colleagues in the laboratory, dietetics department, district nurses and PCC nurses and eye department to provide a comprehensive service to people with diabetes.
DevelopmentsThe diabetes population in Gibraltar has increased by 80% since 2009 largely due to the teams efforts in early identification of people with diabetes (earlier screening) and the development of a Diabetes Register. There are currently 2,575 people on the diabetes register. Many of these people do not see the Diabetes Specialist Nurse for the annual review clinic. Regular reviews allow the opportunity to identify and treat symptoms before they develop complications of diabetes. It is therefore recommended that all patients with diabetes are offered annual reviews and this is one of the aims of the team.
The Adult Diabetes Insulin Pump service developed further in 2015 with a further 7 adults commencing insulin pump therapy. Insulin pump therapy requires a period of education and preparation and commitment from people considering this form of treatment. This has brought personal and clinical benefits for those adults involved and has been a useful investment in terms of resources and time. D
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The insulin pump service will be continued with the plan that an annual ‘pump start’ service can be established to help people to benefit from technological advances in treatment.
The use of continuous glucose monitoring has also increased with further investment of 4 additional meters to facilitate this.
In 2015 the team devised a diabetes education programme for Moroccan sub-populations as there is a high incidence of diabetes in this group and scarce educational resources available to them. This will be rolled out in 2016.
Diabetes Specialist Nurse Julie parker was invited to speak about the success of the Desmond diabetes programme at conferences in Barcelona (2014) and Birmingham (2015).
The GHA now has three DESMOND Diabetes Educators.
Attendance at UK study events and conferences gives the opportunity to network and benchmark local services against those in the UK. The adult diabetes team visited Bournemouth, Manchester and London.
There have been significant developments in the Paediatric Diabetes Service. After completing an Insulin Pump Degree Module with York University, the Paediatric Diabetes Specialist Nurse has commenced four children on insulin pump therapy in 2015 that are progressing well.
The GHA Diabetes Strategy is in the process of being developed.
4. PRIMARY CARE SERVICES
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4.1 PRIMARY CARE ADMINISTRATION This report is intended to provide an overview of the various administrative services provided at the Primary Care Centre, and to provide an update of the status of assessment activity undertaken by each unit within administration.
The aim of the Administrative Service is to support the different sections at the Primary Care Centre by:
Providing a safe and efficient environment
Developing appropriate use of new technologies
Providing outstanding service to all customers registered at the Primary Care
Assuring well-maintained building and grounds
Supporting all members of staff in their daily function
The Administrative Service is comprised of 9 sections with 40 Employees. A brief summary of the responsibilities of the nine departments included within the administrative service are presented below:
Unit General Manager & Primary Care ManagerThis office is responsible for the overall supervision and coordination of various administrative departments within the Primary Care Centre. It interfaces with other Government Departments including the Pension Department and Department of Health in UK. It also deals with all environmental and safety training as well as compliance with Government and GHA Policies.
Primary Care Administrator This office oversees the Records Department and coordination of the administrative staff. It is also responsible for the smooth running of clinics, on call duties and community sessions.
Records Department This department is responsible for manning the main counter and for the smooth running of all clinics. The office is composed of 16 clerical officers.
Registration Department This department is manned by 4 officers whose main responsibility is to register all eligible persons into the Group Practice Medical Scheme. This office also interfaces with other Government Departments including other EU Member states when registering / dealing with EU applications.
Administrative Support – Dental Department / Nursing Departments / AHPs DepartmentAdministrative support is provided to all clinical departments.
Quality Improvement A telephone audit was carried out to ascertain the time it took a patient to get through to our advance appointment telephone line service. Based on these results, the PCC has successfully managed to reduce waiting times from 20 minutes to 15 minutes during peak hours. This has been achieved by allocating two extra staff members to the 5 already in place.
The Primary Care Centre received numerous complaints about the advance appointment telephone line service, as after playing the message, it disconnected the caller automatically. This caused the person to call on various occasions. However, together with the IT Department, the Primary Care Centre was able to successfully upgrade the telephone system which now allows the caller to remain on hold in a queue system.
4.2 DENTAL DEPARTMENT
OverviewThe department provides the following services:
Children’s Dentistry
Dental care to individuals with special needs
Oral surgery - emergencies, maxillofacial surgery and facial lesions
Braces - fixed and removable
Dental Care for welfare patients and prisoners
24/7 emergency dental cover
Staff in the department consists of:
Consultant - Orthodontics
Senior Dental Officer - Speciality-Oral Surgery
Senior Dental Officer - Speciality-Orthodontics
Dental Officer - Orthodontics/Paedodontics
2 Dental Officers - Paedodontics
5.5 dental nurses
Clerical Officer
Day at the Dentist – Dental Health InitiativeThe 4th annual visits of the year 1 school children to the department continues to be a success. The aim of this programme is to ensure that all entitled school children have a dental check-up around the time when their adult teeth first emerge. All 452 Year 1 children were invited to attend the department with their classmates and had the dentist check their teeth, show them how to brush their teeth properly and generally introduce them to the dentist in a welcoming and friendly environment. The visit also provided the opportunity to give the children further appointments depending on their dental needs, removing the reliance of parents to initiate contact with the dentist.
The statistics collected by the department show that, not only are increasing numbers seeking to use the service, but that the dental health of Gibraltar children is similar to that of the UK and is steadily improving.
The programme can only continue with the assistance of the Department of Education, Department of Public Health, teachers and head teachers. The increase in patient number has put more pressure on the service. The development of the 5th dental clinic at the Primary Care Centre will address this together with the employment of an additional Dental Officer.
Oral Surgery Waiting List Initiative In Oral Surgery there has been a push to enhance services, driven mainly by a need to reduce waiting times for operations. This has been achieved by increasing the number of sessions. There has been a dramatic reduction in waiting times, particularly for those patients with acute disease and those whose condition can be treated under local anaesthetic. A reduction in waiting times for non-urgent operations under general anaesthetic is likely with the addition of a whole day’s operating session. Currently, people with oro-facial diseases requiring urgent management are typically seen within two weeks of referral and treated within four weeks. This compares well and conforms to guidelines that have been set by the National Health Service in the United Kingdom.
Preventative Dental CareThe department continues to monitor the dental health of Dr Giraldi Home, St Bernadettes Centre and St Martin’s School. The department is also in regular contact with Social Services to ensure “children in care” have access to the service.
4.3 PRESCRIPTION PRICING AND ADVISORY UNIT (PPAU)The Prescription Pricing and Advisory Unit have been entrusted with various supportive roles within primary care, since its inception in 1999. Although it is staffed by only a handful of hardworking and knowledgeable staff, its remit is very extensive. Its roles include both back office administrative tasks, as well as patient facing services.
Administrative RolesIts primary function has historically been to
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act as administrator to the GPMS (Prescription Scheme) and liaison between the GHA and community pharmacy contractors. Within this role, the PPAU annually processes almost 250,000 prescription forms dispensed by local pharmacies and whilst doing so attempts to improve prescribing practices and patient safety. In addition, all handwritten prescriptions are processed and electronically entered once they are submitted to the department, ensuring all GHA prescription information is readily and promptly available to the prescriber, on the patient’s electronic medication records.
Part of the GPMS administrative role includes providing monthly updates to the Gibraltar Drug tariff, as well as periodic updates to the Gibraltar National Formulary to try and encompass new initiatives and assist in healthcare provision in general.
Patient/Healthcare Professional Facing RolesThe PPAU offers patients assistance with obtaining chronic medication in the event of
a medication shortfall, while awaiting a GP appointment. The PPAU liaises with patients GPs, pharmacists and other healthcare professionals, to verify need for medication and organise the issuing of prescriptions. The PPAU also runs and administers the GHA endorsed emergency supply system, which authorises pharmacies to issue a limited amount of chronic medication to Primary Care Centre patients who have genuinely run out of medication and have an appointment booked. This further extends the unit’s ability to help meet genuine, chronic medication needs, reinforcing the PPAU’s role as a vital resource for patients unable to see their GP and running out of their regular essential medication.
The PPAU also assist patients and healthcare professionals with medication and prescription queries originating from secondary or tertiary care contractors. It helps transpose and translate Clinica Radon and Xanit prescriptions and discharge letters, to aid local prescribers and pharmacies in issuing the GHA reimbursable equivalent, to help provide seamless care.
Part of its role is also to assist patients in sourcing their medication by helping them find a pharmacy which stocks a particular item, if it is in short supply or difficult to find. If none is available the PPAU liaises with the prescriber and pharmacies to try and obtain an available alternative, thus ensuring, as far as is possible, that the patient does not go without.
We also help formulate and run different initiatives to improve patient care within the primary care pharmaceutical provision remit and serve as a valuable information resource for healthcare professionals and patients alike. The PPAU supplies information concerning medication availability, licensing and contraindications, and dosing to assist with prescribing and patient safety and to offer assistance with signposting where required.
Repeat Prescription Post boxA post box with the relevant application form has been set up in the PCC’s main waiting area to facilitate patients obtaining a “Last Prescription Appointment” only. It is used when the patient’s last prescription is due to be dispensed or has been dispensed, but not before, this is an alternative to requesting a Last Prescription Appointment in person.
This service has also been extremely useful for the staff as it enables them to administer the booking of appointments, decongesting the appointment requests received at the counter and requests made via the telephones.
The PPAU is always striving to improve its services, increase its efficiency and assist patients in having the best possible healthcare experience within its remit and beyond.
4.4 MEDICAL SERVICESFrom 2014 to 2015, the Primary Care Centre has seen a significant increase in the number of General Practitioners. The GHA has recruited 3.5 more doctors to undertake General Practice bringing its numbers up to 20.
The department has also seen the appointment of a Part-time Palliative Care GP to focus on improving a patient’s quality
of life through managing pain and other distressing symptoms associated with a serious illness in their home or at the Cancer Relief Centre.
4.5 PRIMARY CARE NURSING The Primary Care Nursing Team has continued to improve and develop its services in their commitment to deliver the highest standard of care to patients on site and in their home environment. Nursing staff have been closely involved with the electronic health record programme which was launched in June 2015. Primary Care services formed part of the first phase and Nursing staff have quickly and efficiently adapted to the changes required for their current working practices.
Nurse PractitionersNurse Practitioner Elizabeth Borges, as a member of the British Primary Care Respiratory Society, has taken the lead in respiratory care, introducing best practice guidelines and innovation in respiratory care. She has been liaising with GPs, A&E and Nursing, introducing first point of care guidelines for asthma and other chronic respiratory conditions, and scheduling of follow up quick access appointments to her clinics.
District NursingThe district nurses have undergone significant training and update this last year, having participated in the internal training modules provided such as palliative care, infection control and dementia care. All candidates successfully completed to a very good standard.
Child HealthChild Health Services operates from the Primary Care Centre providing specialist skills in the monitoring and assessment of child development, family support and child protection. The team comprises of two health visitors and five senior registered nurses offering services from birth to 18 years of age. These include primary home visits, hearing testing, well baby clinics, specialist paediatric clinics, enuresis clinics,
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assessment of developmental milestones, and the management and administration of the childhood immunisation programme.
In addition they run a School Health programme which provides pre-school entry assessments, monitoring and health education sessions to First and Middle school children and a drop in service for senior schools. The staff also hold annual information sessions for school teachers.
The Child Health department works closely with the Social Services department in relation to the Safeguarding of children. This represents a very significant portion of the Health Visitor workload.
In 2015 the department introduced the new-born hearing screening programme which replaced the 8 month distraction test. This procedure allows the identification of hearing loss within 10 days of birth, enabling the formulation of a treatment plan which will ensure that a baby identified with hearing loss will not suffer consequential development
delays due to the hearing impairment. The initial test AOAE (Automated Otoacoustic Emissions) has since its implementation in April been successfully carried out on 445 children.
In July of 2015 staff undertook further training to introduce the second stage assessment AABR (Auditory Brain Stem Response) which is carried out following a failed AOAE assessment and determines whether the baby requires referral to a specialist centre. A total of 24 babies have undergone this test since its implementation, with only one referral required for specialist attention.
The overall benefits of this initiative for the children are significant in relation to their normal development in the achievement of milestones. For the families the introduction of the AABR has resulted in the removal of what constituted considerable stress and disruption.
In 2014 the Meningitis C vaccine was added to the childhood immunisation programme.
School Years 12 and 13 were included in a catch up programme. This vaccine was replaced by the Meningitis ACWY which included the C component and additional strains. This was again followed by a catch up programme for school years 13. 2015 also saw the introduction of the Meningitis B vaccine for all babies born as of September 2015.
The department will look to further develop the hearing programme to include pre-school children in order to identify children with acquired deafness.
Dermatology ServiceAdditional developments are the introduction of the skin cancer screening day, and open access day where members of the public with concerns about skin lesions were invited to attend without previous appointments and be examined by a member of the Dermatology team which included two consultant dermatologists, the dermatology specialist nurse and a GP with a special interest in Dermatology.
There were over 307 attendances on the day and feedback from the public was extremely positive.
Practice NursesThe lymphoedema nursing clinic received a second place award at the British Journal of Nursing annual ceremony. The journal recognised the team’s work in developing a totally nurse led service in response to the needs of the community and providing the latest techniques and practice in the field.
Cardiac Rehabilitation ServiceCardiac Rehabilitation is another service which received a third place award at the British Journal of Nursing Awards. The Innovation award acknowledges the work of nurses who had started a service and maintained and developed it.
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4.6 OTHER SERVICES
Electronic Health Record On the 24th June 2015, the Primary Care Centre introduced EMIS Web (Egton Medical Information System), patient’s electronic record.
This system will help transform the provision of frontline care, ensuring better outcomes for patients and increased efficiencies not only within the Primary Care Centre but throughout the Gibraltar Health Authority. The electronic healthcare system will provide healthcare staff with instant access to accurate patient information and effective tools to communicate, or refer patients, across multiple healthcare settings and enhance support for care in the community.
Big Hand System The implementation of digital dictation technology to the Primary Care Centre has proved an economical and practical process which can be utilised across the GHA resulting in an improved service to patients through quicker turn-around time of correspondence from clinician, to secretaries to patient. The electronic workflow supports mobile and flexible working arrangements therefore helping to alleviate the management of workload across the organisation, plus developing a cross-over support for secretaries during holidays and unplanned absence in turn improving staff satisfaction.
British Sign Language - Video Link
The Primary Care Centre introduced the British Sign Language Video Link Service for patients with hearing impairment. British Sign Language is a visual form of communication using hands, facial expression and body language useful for people with hearing impairment.
British Sign Language interpreters allow communication to take place between people who have a hearing impairment and clinicians.
This facility has been installed in the Dental Department, and the three GP clinics.
During 2014, a text mobile phone service was also introduced to assist people with hearing impairment to make advance appointment bookings over the telephone.
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5. SECONDARY CARE SERVICES
5.1 AMBULANCE SERVICEThis department is divided into two sections; The Emergency Ambulance Service and Patient Transport Service. The latter is staffed by 9 Ambulance Care Attendants (ACA) and is responsible for cross-border inter-hospital transfers, local transport of dialysis patients, transfers of patients to and from other local agencies and supporting the emergency service as drivers, when this service has manning shortages. The emergency service, together with the Gibraltar Fire and Rescue Service ambulance, covers all medical/trauma emergencies in our community. Its complement includes 18 Emergency Medical Technicians (EMT) and 4 registered Paramedics. Other staff include one Patient Transport Service dispatcher, one Station Officer and the Chief Ambulance Officer.
DevelopmentsThe introduction of the Paramedic Response Vehicle has had a significant positive effective on pre-hospital care with Paramedics being able to support fellow EMTs with advanced skills at a moment’s notice and assist GFRS controllers in triaging calls.
The introduction of a Paramedic Clinical Governance framework ensures patient best care and quality assurance of paramedic practice. The EMTs’ and ACAs’ performance and clinical skills are also monitored by an appointed ambulance clinical development and training officer.
The Ambulance Service continues to work very closely with other emergency services and agencies. As a result the service has trained the Royal Gibraltar Police maritime section and Gibraltar Port Authority mariners in the management of casualties at sea. Major incident response and training has been reviewed and more effective methods are now in place.
FutureIt is planned for the transfer of the Gibraltar Fire and Rescue Service ambulance over to the GHA ambulance service and will provide an integrated pre-hospital service to the community.
Plan to train the existing four paramedics to practitioner level with the aim of improving
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patient care and supporting community clinicians.
5.2 A&E DEPARTMENT The Department provides access to emergency nursing and medical care 24 hours a day, 365 days a year to over 33,000 potential patients. The team provide clinical services to treat a wide range of problems with which patients require either emergency or urgent care without prior appointment, either by their own means or by ambulance. The clinical team seeks to provide patients with the best clinical care as quickly as possible, as well as to allay the distress and anxiety that is often associated with accidents and emergencies.
In June 2015 the GHA went Live with the new Electronic Health Information System and A&E, together with the Primary Care Centre were the first departments to implement this. All patient details and data collected during a patient’s episode of care within A&E is now stored in the system.
In 2015 a section of staff successfully completed the BIPAP Non-Invasive ventilation training session. An on-going programme has been developed for A&E staff to improve staff ’s knowledge and skills in assisting the Intensivists with intubation in the department with the aim of improving the management of the critically ill patient.
The last two years have seen the largest and most tangible improvements in the A&E Department in a long time.
1. The refurbishment and re-design of the Waiting Room is complete.
• A new patient reception area has been developed.
• A window with call button connects the waiting area with the new Ward Clerk Office, which now forms an integral part of the Department and improves security for staff.
• A TV screen in the waiting area streams information about A&E procedures and GHA Services keeping the public attending A&E informed.
2. Ward clerk cover.Since March 2015 the A&E department has six ward clerks who work a 24/7 Rota to cover the reception area.
• Advantages include:
• The Waiting room is now overseen by a member of GHA staff virtually all the time.
• Timely reception of new attenders
• Registration of non-entitled patients without time consuming administrative procedures
• A friendly face for patients waiting to be seen, in the previously isolated waiting area
• The retrieval of patient notes is now done quickly by the ward clerk without the need of calling in Records Staff
• Administrative work is now done as needed
3. Medical StaffThe recruitment of extra A&E clerks has improved the cover for the department throughout all shifts.
The new Rota incorporates internal cover making the department independent of the need to use locum doctors.
An Associate Specialist has been appointed. The main role is to coordinate Rotas, organise departmental teachings and represent A&E at the Medical Executive as well as other managerial and strategic roles.
4. Symphony, the Emergency Department Information SystemThe A&E was the first department in the Hospital to introduce the Electronic Patient Program (EPR). The journey from planning to implementation has been a great learning experience for all staff and serve as a blueprint to roll out the EPR program throughout the GHA.
Training of over 50 staff was accomplished through a “train-the-trainers” programme. Experienced users share their knowledge with others and assist with queries and
problems. The project was overseen and supported by GHA Project Managers.
On June 24th 2015 the department went live with the new EPR program. The implementation process was seamless and a great success. Benefits include;
• The Electronic Manchester Triage Tool
• Patient history as well as scanned documents and investigations are immediately available
• Workflow monitors highlight progress of interventions and help in assisting triaging
• Appointments for the dressing clinic can be booked electronically.
• A variety of audits can be undertaken such as attendance numbers, incidence of illnesses, admission patterns and waiting times
5. Remote MonitorsAll of the patient cubicles in the “Majors” area of the Department have been fitted with observation monitors that display vital observations.
All information is displayed and stored on a central monitoring system allowing observation, analysis and quick response to any clinical information.
6. A Road-map for the futureThe re-development of the A&E Department which will include an extended waiting and clinical area are at an advanced planning stage
The strategic plan for the coming year includes the expansion of “Point-of-care” testing devices for several blood tests giving results within a few minutes. The benefits of this will be a quicker response to abnormal results and shorter lengths of stay for patients.
5.3 HOSPITAL OPTOMETRY The Hospital Optometry Department is based within the Ophthalmic Unit of St Bernard’s Hospital. The department consists
of two full time Hospital Optometrists who are responsible for the delivery of the following eye care services.
Children’s Service Children who are found to require vision correction following vision screening by the Orthoptist as at age 4-5yrs, are tested and reviewed regularly until age 8. Over 8 year olds are discharged when the visual system has finished developing and there is no longer a risk of developing a lazy eye. Exempt patients and those with special needs are kept under review beyond this age. A service is also provided for children in Care.
Adult Refraction ServiceThis service provides refraction and disease detection/management to the following: Hospital in-patients, residents of Ocean Views, Elderly Care Agency, Jewish Home, Dr Giraldi Home, Her Majesty’s Prison Service and those in receipt of social assistance benefit. Additionally the dept. provides refraction for Ophthalmic Unit patients who have an eye condition affecting their vision and/or who have undergone eye surgery, the most common being cataract extraction.
Outpatient ServiceThe aim of this service is to exclude and diagnose common eye conditions in referred patients such as cataracts, retinal problems and glaucoma.
Medical Contact lens ServiceThis service was introduced in 2013 for patients who are unable to obtain appropriate levels of vision with spectacles, due to conditions affecting the cornea e.g. corneal scars, grafts and degenerative disorders of the cornea such as keratoconus. These patients are fitted with contact lenses with the aim of achieving a level of vision which is not achievable with spectacles. Complex cases or patients with disease progression are referred to Moorfields Eye Hospital in UK for treatment.
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Diabetic Retinopathy Screening and Co-ManagementThis provides screening for the ocular complications of diabetes primarily affecting the retina known as Diabetic Retinopathy (DR). Those diagnosed with DR are either monitored or referred to the consultant for treatment depending on the risk to sight. The department works closely with the adult diabetes nurse specialists.
Glaucoma and Ocular Hypertension Screening and Co-ManagementThis provides further investigation techniques to enable a diagnosis of glaucoma or ocular hypertension for high risk groups referred to by opticians or GPs. Ocular hypertension cases are monitored for progression to glaucoma. The optometrists also monitor patients with stable glaucoma and ocular hypertension on treatment.
Low Vision ServiceThis is a service for patients with visual impairments to maximise their full visual potential with both spectacles and different low vision aids. Low vision aids are issued on a loan basis, and general advice is provided to aid rehabilitation and blind and partially sighted registration is discussed and undertaken if required. Additionally patients are referred to the GHA’s Rehabilitation Officer for the Visually Impaired to support their rehabilitation in the community and their use of the Low vision aids provided.
DevelopmentsThe Ophthalmic Unit now benefits from a corneal topographer purchased in 2015. This machine maps out the curvature of the front surface of the eye and so aids diagnosis and monitoring for progression of degenerative corneal conditions. it also supplements correct contact lens fitting.
A new tonometer was introduced to measure intraocular pressure (ICare Tonometer). It is a hand held easy to use machine, with results comparable to the gold standard Goldmann tonometer. It does not need anaesthetic eye drops and is quick and easy to use, so it is useful for all patients including those
on wheelchairs, patients with cognitive difficulties and children.
Future The Optometry Department continues to face the challenge of an increasing population with Diabetes requiring Diabetic Retinopathy Screening, whilst alongside delivering its core Optometry services. The ultimate aim of a screening program, is to target as near to 100% of the screening population as possible. In order to do so, a change in service delivery model and additional resources are required to be able to meet the demand.
Space continues to be an issue for the whole Ophthalmic Unit as we are currently working to full capacity. It is hoped that additional clinical space is provided for Optometry, which would release existing space for Ophthalmology.
The Optometry department aims to continue developing services for those most in need and unable to communicate any visual problems. This will involve developing eye care services in the areas of dementia, stroke, mental health, vulnerable adults and children.
5.4 ORTHOPTIC DEPARTMENT
BackgroundOrthoptists diagnose and manage a variety of eye conditions, specialising in squints and disorders of binocular vision. They assess and manage patients of all ages and work autonomously as well as in multi-disciplinary teams. The work includes:
• Assessing babies and young children for vision defects
• Routine vision screening for children starting school in Reception year
• Assessing patients before and after surgery for squints
• Treating amblyopia during critical development period in children
• Treating adults with double vision which can be associated with other conditions such as diabetes, thyroid disorders, neurological
conditions e.g. multiple sclerosis
• Treating eye coordination deficits in children and adults using Orthoptic exercises
• Ensuring speedy rehabilitation of patients who have suffered stroke and acquired brain injuries and have vision problems
• Monitoring glaucoma and diabetes as part of a multidisciplinary team - long term eye conditions
Orthoptists are ideally placed to ensure effective services for patients. They work closely with Ophthalmologists and Optometrists within the Ophthalmic Unit in a multidisciplinary team to treat and formulate management plans for diseases such as diabetes, glaucoma and other neurological conditions.
DevelopmentsThe Department’s proudest achievement in 2014 was its formal accreditation as a Teaching Placement Centre for Undergraduate Orthoptists. In early 2014, two representatives from the Educational branch of the British &
Irish Orthoptic Society visited and awarded the Department accreditation to receive students. From 2014 – 2015, the Department supervised a number of students at various stages during their degree, teaching them valuable core skills and assessing them against the University curriculum, with the assessments counting as part of their degree. The Department is proud to be contributing towards the future Orthoptic workforce and raising the profile of St. Bernard’s Hospital as a teaching hospital.
In 2015 the Colorimetry Service was introduced, in collaboration with the local Gibraltar Dyslexia Support Group. This is in essence an extension of the already existing coloured overlay assessment and results in the prescribing of Precision Tinted Lenses to help reduce Visual Stress and make reading more comfortable in those suffering from Visual Stress. This service was not previously available anywhere in Gibraltar or the South of Spain, which meant that patients had to fly to UK for assessment.
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5.5 OPHTHALMOLOGY The Ophthalmic team continue to undergo in- house training to ensure high quality standards of patient assessments, treatment and better flow for patients through the department, this together with the one stop clinics has assisted in eliminating waiting times for patients requiring Cataract Extractions under Local Anaesthetic.
Nurse led clinics have continued to impact on the number of patients that the department is now able to attend to. This includes a continuous improvement in the number of ophthalmic conditions diagnosed and treated in house and an extension in the services provided to the General Public.
5.6 SPEECH AND LANGUAGE THERAPY
BackgroundThis report encompasses all services provided by the Speech & Language Therapy department within the GHA. The aim of this department is to provide evidence-based services that anticipate and respond to the needs of individuals who experience speech, language, communication or swallowing difficulties. The department works in partnership with these individuals and their families and with other professionals and agencies to reduce the impact of these often isolating difficulties on people’s wellbeing and their ability to participate in daily life.
The department is comprised of both Paediatric and Adult services with specialist streams within each area.
The Paediatric service consists of two separate caseloads, Mainstream and Special Needs with clinical leads heading each area. These services are responsible for children (from neonates to adolescents of 18 years of age)who present with communication, swallowing and feeding disorders including diagnosed genetic and medical conditions, developmental delays, learning disability, hearing impairment, autism and specific speech and/or language difficulties. Service locations for these services include: Mainstream schools, Learning Support Facilities (LSF), Special School and Special
Needs nursery, outpatient clinics at Primary Care, Rainbow Ward and the community. Both service streams within paediatrics have benefitted from staff recruitment within the time frame of 2014 and 2015. In March 2014 a Senior II Speech & Language Therapist was employed to work alongside the clinical lead within the mainstream service and in the following year another Senior II therapist was recruited within special needs.
The Adult service is responsible for clients with swallowing and communication difficulties resulting from stroke, neurological disorders, cancer, dementia and voice disorders. The range of disorders which present can include aphasia, dysarthria, dyspraxia, dysphonia, dysphagia and dysfluency. Locations for this service include inpatient and outpatient clinics within St Bernard’s Hospital, Elderly Residential Services including Mount Alvernia, John Machintosh Wing, Calpe and Cochrane wards and community.
Developments
Paediatric ServiceWithin this area of service provision the following new services were introduced:
National Autistic Society (NAS) EarlyBird Parent Training programmes were commenced in February 2014 run co-jointly with the Occupational Therapy Department. This training is comprised of a 12 -week training programme aimed at empowering parents towards working with their autistic child and helping to develop interaction and improve behaviour.
Audit feedback presentations to schools were introduced by the Mainstream service. These presentations provided the schools with the results of the mainstream audit and informed schools of subsequent changes in the referral process and service delivery on account of this audit.
Autism Diagnostic Observation Schedule (ADOS) training. This department initiated multi-agency training for staff from Speech & Language Therapy, Occupational Therapy, Clinical Psychology and Educational Psychology in the use of the
Autism Diagnostic Observation Schedule (ADOS-2). The course was held at the School of Health Studies and run by an accredited trainer from Great Ormond Street Children’s Hospital. The outcome of this training is a larger number of trained personnel to assess children with autism thereby reducing the impact on individual teams.
Autism Pathway. This department is involved in the identification of a patient -centred pathway that meets the needs of children with autism and their families from diagnosis to intervention. An inter-agency working party has been set up to help develop and ratify this pathway in line with NICE guidelines and in consultation with the local Autism Support Group.
Extension of services of children with special needs provision. The recruitment of an additional member of staff has facilitated an increase in the holistic, targeted speech and language therapy intervention and support within both special school and Learning Support Facilities (LSF) provision in mainstream. In particular, LSF service locations are benefitting from more intensive and cohesive intervention that incorporates team liaison and parental inclusion via weekly case conferences held within the school setting.
Autism Triage clinics have been set up within the department. These are run by both senior paediatric therapists and aim to identify Autistic Spectrum Disorders early thereby facilitating timely intervention which is in line with good practice.
Attendance at yearly National Autistic Society Professional conference in UK. This enables the therapists to remain at the forefront of any new developments in the field and to improve professional contacts.
Adult ServiceWithin this area of Speech & Language Therapy the following developments were introduced;
• Providing on-going training to other professionals, students and carers in specific
areas of communication and swallowing intervention. These include:
• Joint presentations with dieticians to nursing students regarding feeding issues in palliative care
• Teaching on the Acute Stroke Module, held by Kingston University
• Delivering a rolling programme of Dysphagia training to student nurses
• Training staff and carers within the Elderly Residential Services on Dysphagia management.
• Running a “Care of voice for Teachers” training programme. This preventative measure is aimed at helping teachers to keep their voices strong and avoid the development of voice disorders.
• The clinical lead therapist for the adult service has formed part of various committees responsible for the identification of effective patient services within specific medical conditions. These include the Dementia Day-care Facility and the Stroke Initiative. In relation to the Stroke service the Speech and Language Therapist was shadowed by a visiting stroke consultant and invited to engage in discussions aimed at benchmarking existing services for stroke whilst planning future initiatives in accordance with the National Institute of Clinical Excellence, the Royal College of Physicians and the Royal College of Speech and Language Therapist guidelines.
• As a means of extending her knowledge base and providing specialised care to laryngectomy patients, in June 2015, the therapist responsible for this service took part in a working placement within a leading UK hospital specialising in this area.
Continued Professional Development (CPD)This department is firmly committed to CPD and all members of staff are proactive in the pursuit of learning and developing their specialist skills. This is reflected in the
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various academic achievements listed below;
• Clinical lead in Mainstream Paediatrics continues a distance learning PhD at the University of Sheffield. During 2014 pilot data was collected on four children during their regular speech therapy sessions. This data is being used to prepare a parent training programme.
• In October 2014 the clinical lead in Paediatric Special Needs completed a distance learning masters and obtained a distinction in MEd Autism at Birmingham University.
• In November 2014 the Paediatric Special Needs therapist also upgraded her GHA Learning in Action management qualification to level 5.
• In November 2014, the senior II paediatric therapist (mainstream) attended a training programme in UK on the practical management of eating and drinking difficulties in children. This is a basic qualification in paediatric dysphagia management, accrediting and equipping the therapist to become involved in the GHA Feeding Clinic.
Future plans for the serviceThis department firmly believes in the collaborative approach to remediation and values working in partnership with families. Disseminating information and empowering carers is seen as a fundamental future objective and to this end, this department is committed to continue developing training programmes in the following areas:
• Whole school training in the use of effective strategies to support speech, language and communication needs in mainstream settings.
• Developing Dysphagia competencies in nursing staff ,other professionals and carers
• Raising autism awareness in schools and within the wider community.
• Other major future plans involve: extending the adult speech & language therapy service to effectively meet the needs of the elderly population in residential homes and long stay wards
• Working towards the establishment and ratification of a recognised care pathway for autism.
5.7 MENTAL HEALTH SERVICESThe main focus during 2014 was the continued planning for the move to the new mental health facility. Although many improvements have been seen following the move, it is anticipated that the reconfiguration of the services will eventually offer more effective clinical care pathways that are integrated across acute, community and residential care settings. This has been necessary to ensure that service users and families are supported at all stages of the care journey and in the setting that is most appropriate to their needs.
Ocean Views - New Mental Health Facility
During 2014 preparations for the move to the new facility continued. These preparations included a number of discussions and consultations with the general public, support groups, clinical staff, service users and their families to explore and finalise the needs and requirements of the new service.
The long awaited migration to the 52-bedded state-of-the-art modern facility, Ocean Views took place on 7th February 2015. This was a historic and truly memorable experience for Mental Health in Gibraltar. It has to be noted that all the members of the team at every level throughout all the departments worked diligently for many months to ensure the transition was carried out according to plans.
The treatment philosophy in Ocean Views reflects a holistic approach in the diversity of its therapeutic programmes. The new treatment programmes currently being introduced are comprehensive and based on a recovery model approach, as many of the service users demonstrate difficulties in a variety of life’s circumstances. Therefore, the programmes have been designed to comprehensively address factors of emotional well-being, social functioning, educational level, environmental influences, and familial issues in a therapeutic environment, where safety and security are paramount.
The new in-patient facility now offers;
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Sky Ward ( Psychiatric Intensive Care Unit – PICU) Sky Ward is a five bedded Psychiatric Intensive Care Unit. Within this area there are 3 close observation rooms with en suite facilities, 2 seclusion rooms and a Multi-Functional self-contained suite. The PICU is an area specifically for service users whose mental health condition requires them to be treated in an environment of therapeutic security for a brief period of time. The unit provides supportive, individualised care for those whose acute episode of mental illness is resulting in disturbed behaviour that requires a safe specialist environment.
Multi-Functional Suite, (MFS)The MFS is composed of two single rooms sharing communal areas. This completely independent suite now provides a safe and secure environment to care for service users, who for specific reasons are unable to be nursed on the main acute admissions ward. These service users may include children or adolescents, vulnerable adults, mothers and baby or forensic cases.
Horizon Ward (Acute admissions ward) The opening of Horizon Ward provides a thirteen bedded mixed acute admissions ward in a homely and secure environment which gives service users a choice of single or double rooms. The main function has been to offer care and treatment within an inpatient setting that respects and allows treatment to occur in the least restrictive manner possible. The staff always encourage and promote independence, self-esteem and personal choice as far as is deemed possible and assist the service user to take an active role in planning their own care. Very positive feedback has been received from a number of service users and their carer’s as to the general environmental improvements, but in particular to the unprecedented freedom of movement now possible due to the new layout of the facility.
Dawn Ward (Rehabilitation ward) 13 bedded unitPatients suffering from enduring mental illness can often find returning to the
community a very difficult and distressing process. A medium and longer term rehabilitation plan has now been developed in order to provide a treatment intervention and care package to assist service users’ re-integration into society.
Rockside Flats (2 Male & Female Rehabilitation Flats)The rehabilitation flats linked to Dawn ward have been designed to assist service users achieve independent living. They are two purpose built residential flats for up to 7 adults suffering from mental illness, they operate on the basis of single gender occupancy. The flats offer communal sitting area, kitchen and bathroom.
Sunshine Ward (Elderly Mentally Ill (EMI) ward) 14 bedded unitThe EMI Unit has been designed to cater for 3 specific areas for old age patients. It offers 4 assessment beds where service users’ mental states can be assessed and diagnosed. There are 9 beds for longer term service users who fall into the Elderly Mentally Ill category, (these are service users who have symptoms of a Dementia type illness and also have residual psychotic symptoms).
The ARC (Activity and Rehabilitation Centre)This is a two floor department attached to the main building that houses a variety of facilities and resources staffed by a team composed of occupational therapists and nursing staff. Their main aims are the assessment and development of personalised programmes in partnership with the Mental Health Multi-disciplinary team. This service now offers both in and out patients support in learning new skills depending on the service user’s specific needs. The ARC offers facilities for service users to engage in a variety of events, outings, activities, personalised work or groups covering a wide range of interests such as arts & crafts, photography, IT skills, gardening, cooking and pamper groups.
Clinical Psychology and Counselling DepartmentThe mental health services comprise of both in-patient and community based professionals, who together provide a wide range of services depending on need. In total there were 723 referrals made to the psychology and counselling department in 2015.
Mental Health Legislation (r(reform of the 1959 act)Critical to the overall service that the GHA offers has been the need to review and update the current Mental Health Act. This has presented some challenges due to Gibraltar’s uniqueness. During the review period the multi-professional Mental Health Act group has continued to meet on a regular basis and is at the final stages of completing this important piece of work. A Command paper was published in February 2015 for public consultation. It is expected that the new Mental Health Act will be in place by 2016.
Community Mental Health Team There have been a number of changes in this department. This includes an increase in psychiatrists, an increase in clinic appointments and the completion of a full refurbishment programme to the Community Mental Health department based at Coaling Island. This was achieved with minimal disruption to the running of clinics and services provided by the team. Following the official opening on the 24th September 2014 , very positive feedback has been received from service users, relatives and members of the public embracing the new therapeutic and welcoming environment.
Training completed in 2014 – 2015Training is always high on the agenda within the mental health services and is viewed as an integral part of service delivery and service improvement, which everyone strives for. Mandatory training within mental health is provided in-house by our own staff from across different grades and this not only builds on staff personal morale but builds a sense of achievement amongst the teams. This includes Mental Health, Fire, Dignified Care and Responsibility Training, Basic Life
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Support, Infection Control, Mentorship, Safeguarding Adults at Risk and Tier one and two Child Protection. This is important to provide holistic care which focuses on recovery.
5.8 DEVELOPMENTS IN 2014Preparation for the opening of Ocean Views
In preparation for the much awaited move, a migration plan was identified which focused on teams taking responsibility to ensure it was seamless. A review and development of a number of mental health policies took place in preparation for the move.
Improved collaborationAs part of the service development and responding to patient needs, a number of meetings was set up with other service provides both within the GHA and those outside in order to improve access for patients with mental health difficulties who found it challenging to access these services.
This resulted in an improved access for service users with respect to dental, optical and dermatological problems. Members of the Multi-disciplinary team also participated in an exhibition promoting Dementia care, Child-Line and Clubhouse at John Macintosh Hall.
Training Apart from mandatory training, a number of other training opportunities were taken up by staff. These included Venepuncture and Cognitive behaviour therapy, and NVQ2 training.
Fire Safety Management Plan A new Mental Health fire safety management plan has now been completed. It was drafted in conjunction with the UK specialist (Tenos), the Gibraltar fire and rescue service and a small working party from the mental health services. Part of this plan involves fire prevention training and evacuation strategies for the new Mental Health facility.
Clinical incidentsThe mental health service reviewed and implemented their policy to prevent the risk of falls.
Developments in 2015
Multi-Function Suite (MFS)The MFS formed part of the new reconfigured plan for the service. Throughout the year, this new unit has been used to facilitate the care needs of young adults, forensic cases, vulnerable adults, pregnant women and also as a step-down from the more intense nursing input found in the PICU area.
Rockside flatsThese flats have been in constant use and have assisted patients in developing existing skills or learn new ones in order to complete their rehabilitation and eventual reintegration into the community.
Development of groups and activities in addition to ARCIn addition to the facilities provided by the ARC, group activities have been developed in all three wards. These activities which include weekly meetings in order to discuss and plan activities such as arts and crafts, mediation, indoor gardening and social inclusion groups as well as community based outings have been positively received throughout the year by service users and their families who see the positive impact this has on recovery.
Enrolled nurses and NVQ 2 and 3 During 2015, six nursing assistants successfully completed their enrolled nurse training. A further group of nursing assistants started their NVQ 2 training which once completed will assist them in accessing enrolled nurse training.
Registered Mental Health NursesTwo local students who have completed their mental health training in UK returned to Gibraltar and commenced employment with the GHA Mental Health Services.
Electronic Health RecordsA multi-disciplinary mental health group have been working in the implementation of the GHA’s Electronic Health Records program. Work has included a visit to a number of clinical sites in Portugal and the United Kingdom, and to see how the software packages are being used.
Future developments for the service
• Explore the possibility of introducing sheltered employment within the facility
• Develop the ‘Child and Adolescent Mental Health Services’ (CAMHS).
• Continue to develop community services.
• Continue with the work for introducing the new mental health act.
•Introduce the Electronic Health Records program for the Mental Health Services.
• Explore the possibility of implementing ‘Star Wards’ across the service.
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5.9 BED MANAGEMENT St Bernard’s Hospital continues to experience high bed occupancy for adult patients during this period. Additional beds have been used in order to ensure that beds are available for emergency and elective admissions. This has resulted in minimum elective surgical cancellations. This has been possible due to the proactive approach by the GHA’s multi professional Bed Management Team who continue to address the challenges by supporting and improving patient flow in order to have timely discharges.
Victoria Ward continues to utilise its day room for rehabilitation patients.
Bed management meetings continue to incorporate Sister’s & Charge nurses in the format. This continues to be welcomed as first hand input on current & future dynamics can be discussed in a mutually supportive manner.
5.10 CANCER SERVICESA diagnosis of cancer can have a major impact on many areas of a person’s life. They may be dealing with many medical, emotional and financial issues. The GHA endeavours
to make the patient’s cancer journey as seamless as possible, offering advice, support and a range of options. To this end, the new Cancer Services Department aims to improve the patient experience and improve cancer outcomes.
The Cancer Services Department was developed in September 2015 with the recruitment of a new GHA Cancer Services Coordinator. This new role entails the coordination of services between the different cancer service providers such as primary, secondary, tertiary care and palliative care, together with local cancer charities, to ensure best practice in access to cancer services and active case management. By liaising with all service providers, the Cancer Services Coordinator identifies any gaps in care and implements any possible improvements to GHA services such as new patient care pathways, policies and protocols. This new role encompasses managerial, quality assurance and educational responsibilities.
Progress so far has included improved communication between service providers, and there is also an established link between senior clinicians both in and outside
Gibraltar. Oncology multidisciplinary teams meet with clinicians and the palliative care team regularly. A draft Cancer Strategy is already in place, which includes new services that will soon be developed for patients. This will include a Chemotherapy Suite, where patients will be seen by an Oncologist, given their chemotherapy and followed-up post-treatment. Improvements to the service has also included the electronic standardisation of all suspect cancer referrals, as per the new 2015 NICE guidelines.
Part of the service provided by the Cancer Co-ordinator involves working with the Health Promotion Officers to raise awareness as to prevention, screening and symptoms to look out for before going to your GP. The main objective of this is to diagnose cancer at the earliest stage possible in order to improve the chances of a successful outcome. The GHA in partnership with local Cancer charities continue to work on initiatives to get these important messages across to the community. Knowledge is power and
power means action. The Cancer Services department together with the Health Promotion team plan to organise various cancer group specific awareness campaigns in order to provide information to the general public and dispel some taboos.
Further developments in Cancer Services will involve the development of policies and guidelines in order to address some of the difficulties encountered by patients and their relatives such as Social Policies.
Palliative CareThe Gibraltar Health Authority’s Palliative Care Team’s role is to ensure that patients and carers with palliative care needs are assessed, supported and cared for appropriately. Palliative care nurses work closely with multi-disciplinary teams following referrals for care and regularly liaise with other agencies and other Health Care providers to ensure continuity of care for palliative care patients.
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This also includes supporting staff across the GHA and with other agencies, advising and assessing patients when required and coordinating the discharge planning to enable patients to get back to their own homes whenever possible.
5.11 OUTPATIENT SERVICES
Blood Department
Venepuncture training for NursesThe department has started a new initiative in collaboration with the School of Health Studies to train nurses in venepuncture techniques. A total of 30 students have completed this programme.
There has been very good feedback from students and the School of Health Studies.
The Phlebotomy department has seen an increase in attendance with clinic numbers for 2015 reaching over 24,000 patients.
Blood Donation RoomThe new blood donation room which was completed during2013 has been a success with blood donors feeling comfortable and happy with it especially having the television for entertainment whilst donating blood.
The department has also acquired a new computer system, new electronic scales and trolleys.
Department of Medicine The Department of Medicine comprises of 4 full time consultants and 6 Non-Consultant Hospital Doctors. There has been an additional part time cardiologist with 4 sessions per week and a full time cardiac physiologist.
The main services offered by the unit includes General Medicine, Gastroenterology, Geriatrics, Endocrinology and Respiratory Medicine
The services offered are also complimented by a comprehensive Visiting Consultant
programme. This includes Cardiology, Rheumatology, Pulmonology, Respiratory Physiology Haematology, Neurology, Gastroenterology and Nephrology.
The unit also offers a variety of investigations. These include;
Stress test, stress echo, Trans Oesophageal Echocardiogram (TOE)
• BP Monitors
• Sleep studies
• Spirometry
• Bronchoscopy
• Endoscopies (gastroscopy and colonoscopy)
• Bone marrow biopsy
• Anti TNF (biologics) injections
• Pacemaker check
• EEG
• Phlebotomy
As a result of the recruitment of the cardiologist there have been several services that have been repatriated. These have included in-house Echocardiography, Stress echocardiography and pacemaker checks.
5.12 OPERATING SUITE
Operating TheatresThe Gibraltar Health Authority in collaboration with Edge Hill University are currently delivering an acclaimed academic module to four Registered Nurses / experienced Theatre Practitioners based on the Surgical First Assistant role as outlined by the U.K perioperative Care collaborative. The course will cover a number of topics including the legalities of the role, risk assessment, principles of the role from draping, positioning, tissue retraction, assisting with haemostasis and electro surgery.
Future training opportunities will include Operating Department Practitioner training SE
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which will be delivered in cooperation with the School of Health Studies. In the past, all Operating Department practitioners have been trained and recruited from the United Kingdom as it has not been possible to do so locally.
The Theatre Nursing Team together with the Medical Director, Surgeons and the Anaesthetic team continue to work to maximise Theatre capacity and productivity and undertake additional theatre lists such as for Visiting Consultants, Special needs Dentistry and Ophthalmic General Anaesthetic lists.
Day Surgery The Day Surgery unit continues to expand its services and the number of procedures undertaken within the unit with the introduction of General Anaesthetic operating sessions to reduce the waiting list for patients requiring Dental / Max-Fax surgical procedures and General Anaethetic General Surgery.
The Day Surgery Unit continues to undertake on average 85 – 95% of all elective patients requiring surgical procedures of all sub specialities.
Pain clinic / infiltration sessions also continue to be undertaken as well as Cardioversions and Plastic Surgery procedures.
TSSU DepartmentWith the increase of elective Day Surgery procedures and the increase of theatre sessions, TSSU / CSSD has had to undergo modification and development of its services at many levels.
The Department has recently undergone refurbishment and updating of its Steris automated washers and decontamination units to enable it to continue to provide a streamlined service to other departments which include:
• Operating Theatres
• Day Surgery Unit
• Maternity
• Accident & Emergency Department
• Ambulance Services
• Radiology Department
• Dialysis
• All Wards & Clinics in SBH
• PCC
• ECA
• Ocean Views
• HMS Prison
• RGP & City Fire Brigade
• St Johns Ambulance
5.13 WARDS AND DEPARTMENTS
Maternity WardThe Maternity unit in Gibraltar is unique in the fact that all aspects of Midwifery are
dealt with under the one area. This differs from the UK where the wards are divided into antenatal, labour and postnatal care. Our unique environment allows both the women and staff to establish a relationship from the onset of the pregnancy, thus enhancing the fact that the team can not only provide one to one care but also continuity.
The team take pride in knowing that Midwifery colleagues who have visited the unit from the UK have always been impressed and even a little envious of the fact that the GHA offers this standard of care to our women.
Women are waiting longer until they start their families and women with complex medical histories can now become pregnant due to medical advancements. The team has recently commenced an antenatal register for all women with complex medical conditions. An MDT group has been developed to manage these cases. Pre-planned care for these women is designed to safeguard their deliveries.
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Ward attenders seeking advice to any queries have also increased. Staff prides themselves knowing all aspects of the service are readily available.
The Care Audit proves that on the whole the women and their families are generally extremely satisfied by the level of care received by the team and service. Nevertheless the team know that there is always room for improvement.
New initiatives underway are;
• The development of the early pregnancy unit
• Miscarriage and neonatal services.
• A Venous Thromboembolism pathway for high risk women based on NICE guidelines.
• Diabetes in Pregnancy
Rainbow Ward
The service offers paediatric inpatient, outpatient and ward attender facilities. The Unit comprises of three Paediatric consultants working on a rotational basis, sixteen paediatric nurses a part time Paediatric diabetic nurse specialist.
During 2015 the unit commenced the development of the ward attender service to include 24 hour ECG monitoring and increased the Skin prick testing service.
The Critical Care Unit (CCU)The Critical Care Unit comprises of 10 beds which include 3 side rooms and capacity can be increased to a maximum of 13 beds in extreme situations. All admissions are patients who require Intensive or High Dependency care. The unit is overseen by three Ward Managers and a Consultant/Intensivist.
John Mackintosh WardThe General Medical unit in St Bernard’s Hospital offers care for adult patients with a variety of complex medical conditions. As an Acute Medical Ward, John Mackintosh Ward has seen an increase in the number of qualified Staff in order to meet the needs of the acute patient.
The team in John Mackintosh Ward continue to work with Social Services to ensure patients who are admitted with complex needs are assessed for ‘packages of care’ to facilitate successful discharges.
Victoria Mackintosh WardVictoria Mackintosh Ward is a 30 bedded Medical ward which is dedicated to the management of patients with chronic and complex conditions. It is also the dedicated rehabilitation unit within St Bernard’s Hospital. The team in Victoria Mackintosh Ward is dedicated to providing individualised care. By working closely with a Multi-Disciplinary rehabilitation approach, the
staff aim to encourage patients to reach their optimum potential which will enable them to return home or function within their care environment.
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6.1 PATHOLOGY
IntroductionThe Department of Pathology provides a wide spectrum of services including Biochemistry, Haematology, Transfusion service, Microbiology, Histology, Cytology and Anatomical Pathology. It is also responsible for the provision of Public Analyst services. The department provides a very diverse range of tests and is excellently equipped with the latest analyzers using best practice methods. Processes are quality assessed and the staff participate in Continuing Professional Development which is a requirement to remain registered with the Health and Care Professions Council and other professional bodies.
Developments in 2014 and 2015Performance on external quality assurance schemes which include comparisons with hundreds of laboratories, demonstrates that the department performs excellently. This provides confidence to professionals both inside and outside the department that it provides quality, evidence-based services.
There is on-going change in Pathology services and the department aims to keep up to date and provide cutting edge tests that often are not available routinely even in much larger laboratories, such as full spectrum Tumour Marker panels, full allergy screens and Polymerace Chain Reaction (PCR) analysis for microbiological identifications. These are just some of the introductions and improvements over the period 2014-2015;
Introduction of new testsA range of new tests have been introduced to provide a better service to clinicians for diagnosis and patient management. These include;
Brain Natriuretic Peptide (BNP) which provides a useful adjunct to routine assessment for differentiating acute heart failure from other causes of breathlessness
Haptoglobin, used primarily to help detect and evaluate haemolytic anaemia and to distinguish it from anaemia due to other causes
Beta 2-macroglobulin (B2M) used as a tumour marker for some blood cell cancers. B2M helps to evaluate the prognosis of cancers such as multiple myeloma and lymphoma.
Accreditation for the Department of PathologyIn its purpose to produce European Standards Compliant blood components, the Department commissioned an audit of its Blood Donation and Transfusion services. The audit assessed current blood bank systems against ISO 15189 (Medical Laboratories) Standards. This was the first step and the department will now proceed to follow the processes necessary to attain ISO 15189 accreditation.
Carbapenem-Resistant Enterobacteriaceae (CRE) screeningCRE are bacteria that possess high levels of resistance towards many types of antibiotics, including those that are a last resort for such infections. The department has implemented a CRE screening programme to test patients who arrive from external hospitals. This ensures that any positive patients are treated with appropriate levels of isolation, especially in locations such as hospitals and elderly care homes that care for immunocompromised patients. The availability of PCR technology means that results are available rapidly.
The department places great importance on education and development, both for staff as well as students that come to visit from schools, and those that spend time training on honorary placements. The department’s outreach programme includes participation in the Careers Fair where its stand is always popular and where members of staff promote Biomedical Science ensuring there is interest in the profession in Gibraltar for the future.
Future developments and plansPathology Services are essential to the delivery of effective and safe healthcare. The workload continues to grow and is almost 130% higher than when the department moved from the old hospital to this one reflecting the greater
6. DIAGNOSTIC SERVICES
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use of pathology services in healthcare.
An area in which the department is planning to work on this year in order to improve our services is the development and expansion of the Laboratory Information System to enable easier test requesting and result accessibility.
6.2 RADIOLOGY SERVICES
BackgroundThe Radiology Department provides a clinical service for patients of all ages. The Radiology department collaborates with all clinicians across the organisation in all specialties to review patient care and share clinical expertise through a multidisciplinary approach.
The Department consists of a team of Radiographers, Radiologists, administrative staff and assistants who are together responsible for the capture, interpretation and reporting of images from various parts of the body.
The department provides diagnostic services including interventional procedures such as image-guided biopsies and therapeutic services including interventions such as image-guided drainage of abscesses are also offered.
DevelopmentsInstallation of a new 128-slice CT scanner with the latest dose reduction technology has led to a significant reduction in radiation doses and has increased the range of studies that can be performed locally. The department is now able to provide a modern CT angiography service and has 3D CT colonography capability which has enhanced the colon cancer screening programme.
In early 2014, the breast screening mammogram interval was changed to two years for all women between 40–70 year olds. This was as a result of a review of the existing programme and has led to a more targeted service. Ladies over the age of 70 still have the option to participate in the
programme.
A Familial Breast Cancer Screening clinic has also been established. This caters for individuals with higher than normal risk that requires more frequent breast screening as well as genetic testing.
An Abdominal Aortic Aneurysm (AAA) screening programme was established in collaboration with the Public Health Department and commenced in May 2015. The programme aims to reduce deaths due to AAAs amongst men aged 65 and over. A simple painless ultrasound test is performed to detect AAAs and the results are provided straight away.
One major development has been the establishment of a tertiary Consultancy service with Radiologists at St George’s Hospital via an electronic link. The benefit of this is that the GHA can now obtain expert opinions regarding complex cases.
The Department has been targeting waiting lists in ultrasound services. Routine scan
waiting time has reduced to 5 weeks, with urgent scans been performed usually within two weeks of the request.
The department was part of a multidisciplinary team who developed a patient pathway for the management of persistent low back pain. This included an educational section on the imaging of back pain.
The department established an Image Exchange Portal (IEP) which is a network set up for the secure digital exchange of Radiology imaging information between St Bernard’s Hospital and UK hospitals. It is a fast, efficient and secure method that eliminates the need for production and transfer of patient radiology images via CDs to the UK for tertiary referrals or expert opinions.
A new GE Voluson 8 Obstetric ultrasound scanner enables capture of images of high quality, allowing the sonographers to work more efficiently, and thus lowering the recall rate and conforms to NICE Guidelines.
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FutureThe department will soon be completing an upgrade to our Radiology software program which allows for digital dictation and will be much more user friendly.
The Radiology Department is exploring to expand its services in the near future through the expansion of the department and introduction of a new ultrasound room.
With the start of Chemotherapy services within the GHA, the department hopes to establish an efficient Oncology multidisciplinary team service, which will lead to more efficient and safer patient care.
Continuing Professional Development/Clinical GovernanceThe Radiologists continue to engage in multidisciplinary team meetings with their Surgical and Paediatric department colleagues. The Radiologists continue to participate in annual appraisals.
The Radiologists have regular Error & Discrepancy meetings as part of their on-going Continuing Professional Development (CPD). This also includes teaching sessions delivered to GPs, and other medical colleagues, as well as Radiographers.
7. THERAPY SERVICES
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7.1 PHYSIOTHERAPY SERVICES
The department’s vision is ‘Physiotherapy works’ across the spectrum of GHA provided services.
Developments
AHP Stroke Pathway A comprehensive multi-disciplinary team review of a researched based approach to Strokes was conducted.
Multi-disciplinary team Spinal Pathway for the Management of the Patient with Chronic Lower Back Pain
This is in line with NICE Guidelines and was completed and implemented.
The addition of a Physiotherapist working in the Spinal Clinic will improve the Spinal Pathway further.
Clinical and Quality AuditsAn internal review of GHA Physiotherapy Services was undertaken and covered areas of Clinical Governance. This will form the basis of developing Physiotherapy in 2016.
7.2 OCCUPATIONAL THERAPY
BackgroundThe GHA Occupational Therapy (OT) department covers Community, Paediatric, Mental Health, Secondary care in-Patient and Visual Impairment Services. The department provides a wide range of services across the above specialities which include adults and children. It aims to enable function and independence through person-centred and holistic assessments.
Service DevelopmentsThe OT department was involved in some major building projects around Gibraltar. The aim of this was to act in an advisory capacity to ensure the new buildings are accessible, not only for those with physical disabilities but also sensory impairment. This gives them a good quality of life, which facilitates independence in their own home and access to public facilities. This work was highly valued by the architects and building companies involved.
Mental Health The Mental Health OT Team moved into the new Activity and Rehabilitation Centre (ARC) at Ocean Views in early 2015. The new environment has purpose built facilities which means that a higher quality service can be provided to both residential and community mental health patients. The team provides daily activity timetables with a wide range of therapeutic, individual and group activities in a variety of settings. The OTs also provide relaxation sessions for Cardiac Rehab and Bruce’s Farm, as well as a Coaling Island Lunch Group.
Community The Community OT team have a triage system for OT referrals in order to allocate appropriate priorities and manage the demand as effectively as possible.
An OT with a special interest in Palliative Care now works closely with the Cancer Relief Centre, providing continuity of care and one point of contact for palliative patients requiring OT input.
The wheelchair assessment service now has direct links with a specialist wheelchair clinic in Malaga, which enables joint working with the GHA OTs to achieve individual needs-led assessments for the provision of specialist wheelchairs.
Rehabilitation for the Visually ImpairedThis service continues to develop with the OT assessing and providing rehabilitation for people with low vision or visual impairment. This is a service which provides an holistic assessment of the person and how they function in everyday life. It includes providing training with the use of aids/equipment, and understanding of the person’s psychological and emotional needs. The OT also supports and advises carers and facilitates modifications to the home.
St Bernard’s Hospital The OT department continues to work on the Stroke Initiative Pathway to benchmark the current service using the UK NICE guidelines, with the other members of the
Multi-Disciplinary Team. There are joint OT/Physiotherapy weekly groups and daily individual sessions for stroke patients.
The development of an Equipment Criteria Document and Pathway in 2015 has improved the management of equipment in the department.
The Hand Therapy Service continues to have increasing referral rates each year. The clinic runs twice a week and provides assessment and advice for upper limb conditions which may include the use of aids/splinting/exercise and preventative care.
Paediatric OT referrals for children both pre and post a diagnosis of Autism (0-18yrs) are increasing. This has seen a higher number of referrals from mainstream schools and learning support facilities. This has placed additional demands on the services offered.
The OT and Speech and Language Therapist completed the first Early Birds Training
Programme in 2014. This is a specific programme run with the parents of children under 5yrs and newly diagnosed with Autism. It is designed for the parents, to help them with understanding and giving them coping strategies to implement at home. The course runs twice a year and the feedback from the families who have participated has been extremely positive.
The OTs have developed a new system for children in First Schools who have been identified as having handwriting or fine motor difficulties. This is a ‘90 day programme’ with the work to be continued in school and support given to the teachers and parents.
Attendance to the Sensory Integration Conference (2015) and completion of training for the Autism Diagnostic Observation Schedule (2014) has enhanced therapists’ skills and enabled further service development.
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7.3 NUTRITION AND DIETETICS The department of Nutrition & Dietetics provides advice about nutrition and diet in relation to health and illness, helping people to understand the impact of diet on their health.
The department’s aim is to assess nutritional status and offer effective dietary treatment for nutrition related diseases by using evidence based practice, education and support.
Staff in the department consists of 4 registered dieticians based at St Bernard’s Hospital providing a service to in patients, out patients and in the community.
All dieticians have developed particular areas of expertise and offer a wide range of dietetic services.
Nutrition & Dietetic Services include:
Inpatient services
Daily inpatient services (adults and paediatrics) to all wards, including intravenous and nasogastric/gastrostomy feeding
Assessment of renal/dialysis patients
Visits to Ocean Views hospital to assess patients
Outpatient services5 adult outpatient clinics per week
1 specialist Gastroenterology clinic per week.
1 drop-in weighing clinic per week
Weekly cardiac rehab (clinics and talks) as part of the cardiac rehab team
Home visits following health professional’s referral (including Elderly Care Agency, Cancer Relief Centre, Dr Giraldi Home, St Bernadettes)
Paediatric services2 outpatient paediatric clinics per week
Weekly paediatric feeding clinic in conjunction with the speech & language therapist
Outpatient paediatric diabetic clinics every 3 months (multidisciplinary)
Monthly input to St Martin’s special school.
Multidisciplinary team working Monthly palliative care meetings
Regular MDT case conferences.
Education and Health promotionTeaching sessions to a range of staff groups
Public health nutrition - advice and talks/workshops to schools and other organisations.
DevelopmentsOne of the new developments has been the involvement of the Paediatric Dietician in the Autism Working Group, which meets on a monthly basis. One of the first objectives identified by this group is the development of an Autism Pathway which will include a Parent Information Pack.
The department has seen an increase in referrals for the Enhance Recovery After Surgery scheme (ERAS) for patients undergoing colo-rectal surgery. Patients on the ERAS scheme have dietetic input as an out-patient pre-surgery and as an inpatient post-surgery.
7.4 PHARMACY The Hospital Pharmacy provides pharmacy services to the GHA and external agencies such as the Elderly Residential Services and HM Prison.
The Hospital Pharmacy is responsible for the purchasing, importation, stockholding, distribution and dispensing of drugs and pharmaceuticals and other medical and surgical appliances.
The Pharmacy team is composed of one
Head Pharmacist, one Dispensary Manager, three Clinical Pharmacists, one Basic Grade Pharmacist, three clerks and one labourer.
Expenditure on drugs and pharmaceuticals continues to grow as a result of higher bed occupancy levels, increased medical and surgical services and the introduction of new vaccine programmes such as the new Hepatitis B vaccine.
Ocean Views Hospital continues to benefit from regular monthly visits by a pharmacist who attends doctors’ ward rounds, multi-
disciplinary meetings and patient work groups.
The Pharmacy Department was refurbished and extended in 2015 to accommodate new working areas and administration offices which has led to improvements to the general layout of the department.
Clinical Pharmacists carry out regular visits to the acute wards providing valuable pharmaceutical advice to both health colleagues and patients.
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8.1 LICENSING OF DOCTORSBackground
The Gibraltar government elected to office in December 2011 had a manifesto commitment to restructure the regulation of doctors. It stated:
“We will outsource to the GMC the assessments of doctors of licences to practice: and will make the GMC the regulatory body in Gibraltar for the medical profession, so that its standards, rules etc. apply in Gibraltar as they do in the United Kingdom.”
GMC refers to the General Medical Council, the statutory body that regulates doctors in the United Kingdom. To fulfil the manifesto commitment, the Government enacted a new law, by which all doctors who wish to practise in Gibraltar must be in possession of a valid Licence issued by GMC.
The Licence is what gives a doctor the legal authority to undertake medical duties, such as examining patients, prescribing medicines, providing treatments and signing death certificates. Doctors who do not have a Licence cannot carry out any such activities.
Revalidation Licences are issued by the GMC usually for five years and when the Licence expires, it must be renewed by a process called Revalidation. The GMC makes the decision to revalidate a doctor, based on the recommendation of a senior doctor called the Responsible Officer (RO) appointed by the doctor’s employing organisation. However, this structure is limited by law to the UK mainland and has no validity in Gibraltar.
The Minister for Health set up a Revalidation group, which included leaders from the GHA, the Medical Registration Board and the Medical Advisory Committee, to explore strategies to meet the challenge of revalidating doctors working in Gibraltar. The Government also consulted with the General Medical Council and the Department of Health.
It emerged that the way forward was for Gibraltar law to enable the GHA to establish its own Responsible Officer. The appointee would then be able to apply to the General
Medical Council to be recognised under British Law as a “Suitable Person” who would have lawful authority to advise the Council on the revalidation of doctors. Gibraltar Law was changed accordingly.
Responsible Officers In most organisations of the NHS, the Responsible Officer is usually its Medical director, because roles and responsibilities in term of governance of doctors do overlap. In the GHA, however, the roles were separated to enable the Responsible Officer to develop this new role without distraction and a separate post was created.
The Responsible Officer carries out the following functions:
1. ensuring that there are systems and processes in place locally to support doctors in their revalidation, such as annual appraisals;
2. monitoring the conduct and professional behaviour of doctors, and overseeing any fitness to practise procedures; and
3. making recommendations to the GMC about the revalidation of doctors who have a prescribed connection with him.
In November 2014, Dr Safwat Tosson was appointed by the GHA as its Responsible Officer
Suitable Person A Suitable Person in British law is a licensed doctor who the General Medical Council has ·approved as suitable to make a revalidation recommendation about a doctor’s fitness to practice in the same way as the Responsible Officer.
The General Medical Council has strict criteria for the selection and approval of a Suitable Person. In order to achieve the status of Suitable Person, Mr Tosson was required to attend Responsible Officer Training in the UK and must remain an active member of the network of Responsible Officers. The Suitable Person is also required to adhere to the GMC reporting guidelines.
In February 2016, Mr Tosson was recognized
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by the General Medical Council as a Suitable Person under British law.
Appraisal framework In order to make recommendations to the GMC about each doctor’s fitness for revalidation, the Responsible Officer primarily relies upon the Medical Appraisals completed by the doctor once every year during the Licence period.
Medical appraisal is a process of facilitated self-review, in which, once a year, the doctor uses protected time to meet with a trained external appraiser, in order to focus and reflect upon the full scope of his or her work and how it complies with the GMC’s model of Good Medical Practice. It includes a review of professional development, regular training, feedback from patients, any complaints and evidence of quality improvements.
The outcome of each appraisal is sent to the Responsible Officer. Just before a doctor’s Licence reaches its expiry date, the Responsible Officer summates the previous five years of appraisals and makes a recommendation to the GMC, as to whether or not the doctor should be granted a Licence for another five years.
To setup the process of annual Medical Appraisals in Gibraltar, the GHA established a contract with Health Education Wessex to undertake the appraisals of all GHA doctors. The GHA also subscribed to the Revalidation Tool Kit as an electronic platform to support revalidation.
GHA doctors have embraced the appraisal process enthusiastically with 100% of GHA doctors completing their appraisals in the very first year, a record even in the UK.
FutureGiven the complexity of the changes, at the time of promulgating the new law, the Government provided for an 18-month transitional period for doctors to become compliant with the new requirements. By January 2017, all doctors working in Gibraltar will have to possess a Licence to practise issued by the General Medical Council.
It may seem somewhat elaborate and complex, but the aim of this entire framework is to
ensure that the public can continue to have confidence in their doctors at all times and that doctors remain motivated to maintain high standards of care for their patients.
8.2 SAFEGUARDING ADULTS AT RISK
The GHA’s Safeguarding Adults at Risk Team work in close liaison with the Care Agency and other organisations to make Safeguarding everyone’s business and to ensure GHA staff have full knowledge and understanding of safeguarding procedures and how to act when abuse is suspected. Abuse can be physical, financial, psychological, institutional, discriminatory, sexual or neglect/omissions to Act.
The team’s aim during this period has been to maximise training across all GHA disciplines to ensure registered practitioners are aware of their responsibilities to act and report.
Reports of abuse have increased from 4 in 2012/2013 when reporting began to 7 cases in 2014 and to 14 cases in 2015. A proportion of these are identified through A&E or in the community. The increase in numbers probably indicates greater awareness and reporting. It demonstrates that the training GHA staff are receiving is helpful in raising such awareness and encouraging reporting.
8.3 COMPLAINTS HANDLING SCHEME Complaints against the Gibraltar Health Authority are received and investigated by the Complaints Handling Scheme (Health) which operates under the auspices of the Gibraltar Public Services Ombudsman.
BackgroundThe Gibraltar Public Services Ombudsman (“Ombudsman”) was brought into existence upon the enactment by the Gibraltar Parliament of the Gibraltar Public Services Ombudsman Act 1998.
Since 1998, the Ombudsman has constantly kept its operating standards under review with the result that at present, the services it offers is at par with that being offered within
mainstream European ombudsmen schemes.
The Ombudsman is a full voting member of the (British) Ombudsman Association (“OA”) as well as of the International Ombudsman Institute. It also forms part of the European Network of Ombudsmen. The Ombudsman takes a very active part in the OA First Contact Interest Group where it is a leading member. It also cooperates in the Legal Interest Group and is currently exploring means of setting-up an Overseas Members Interest Group.
All investigators are trained and have obtained certificates in Ombudsman and Complaint Handling Practice from Queen Margaret University in Scotland.
The Ombudsman has a statutory duty to report to Parliament on an annual basis its activities and all the investigations it has carried out during the preceding calendar year. Its Annual Reports, together with a plethora of information into the work of the Ombudsman in Gibraltar can be found in its
website (www.ombudsman.org.gi).
The Ombudsman is embedded in Gibraltar’s Constitution and is an Officer of the Gibraltar Parliament. The Ombudsman enjoys the highest degree of independence and is respected as such by all entities under its jurisdiction.
Specifically in respect of complaints against the Gibraltar Health Authority the Ombudsman, pursuant to an agreement with the Parliamentary and Health Service Ombudsman, in the United Kingdom has direct access to the same clinical advice as that enjoyed by the said Parliamentary Ombudsman and all other public sector Ombudsman in the United Kingdom and Ireland.
The SchemeThe Government of Gibraltar in its 2011 election manifesto stated that all complaints against the Gibraltar Health Authority would
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be dealt with directly by the Ombudsman. Whilst the Ombudsman welcomed this as a vote of confidence in the Ombudsman and its work, he also made known to the newly elected Government that it would not be commensurate with ombudsman philosophy to be directly involved ab initio with complaints against any public body under its jurisdiction. The Government of Gibraltar accepted the Ombudsman’s proposals and consequently the Complaints Handling Scheme (“CHS”) (pursuant to an arms-length agreement) became the complaints portal for all complaints against the Gibraltar Health Authority as from 1st April 2015.
The CHS is currently manned by a Complaints Coordinator and an Assistant Complaints Coordinator and together it provides a service to all health service users in Gibraltar. Its mission is to address complaints (informal/formal) resulting from actions of the GHA and attempt to resolve grievances in a timely manner.
Its role is to:
Provide a dynamic, sensitive and responsive complaints handling service
Address all complaints from service users
Be responsible for gathering all relevant facts pertaining to a complaint
Conclude the fact finding exercise and (where appropriate) making relevant recommendations to avoid repetitions of actions leading to specific grievances
Log all complaints and compliments
Implement a follow up procedure
9. SCHOOL OF HEALTH STUDIES
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The School of Health Studies (SHS) offers a range of educational activities. The programmes are proactive, anticipating not only today’s expectations but tomorrow’s demands. The SHS is dedicated to advancing the health and well-being of individuals and communities. Based at St Bernard’s Hospital the SHS offers academic excellence to those taking their first steps in healthcare as well as to practitioners with many years’ experience in their field, creating an exciting and innovative learning environment. Students graduate equipped with the employability skills they need to succeed in a range of healthcare settings along with the foundations for lifelong learning.
The School continues to provide an eighteen month Enrolled Nurse Programme, upon successful completion pupils apply for registration with the Gibraltar Nurses’ Midwives and Health Visitors Registration Board (GNMHVRB) exiting the programme with a Qualification and Credit Framework (QCF) level 3 in Health and Social Care.
On successful completion of the BSc (Hons) Nursing (Adult) degree programme, students apply for registration with the GNMHVRB. This programme provides for the delivery of University level education close to home. SHS lecturers along with the support of GHA clinical staff teach and assess the programme, external validation of academic standards are undertaken by Kingston University London and St George’s University of London.
The School oversees the delivery and quality assurance of QCF level 2 in Health and Social Care which now extends to a range
of GHA staff.
Developments Twelve senior managers are in the final stages of the PGCert, PGDip and MSc in Leadership and Management in Health. This programme concludes in 2016.
The SHS continues to work closely with a number of external organisations such as the Department of Education in raising its
profile and promoting nursing as a career
option in Gibraltar.
Continuing Personal Professional Development (CPPD) In complex, challenging and rapidly changing modern healthcare services it is important for staff to be able to access relevant and flexible Continuing Personal Professional Development (CPPD) opportunities that meet personal and professional needs with the aim of promoting the delivery of high quality, safe and compassionate care that results in improved health outcomes and a better experience for patients, families and carers. The GHA continues to invest in CPPD for all staff within the GHA and this element of the School’s work continues to expand. The modules offered are multidisciplinary with the aim of engaging a wide range of staff from across the GHA. The modules (utilising a range of academic levels) reflect local need and are closely aligned to GHA strategic direction in response to the needs of the people of Gibraltar. Many of the
modules are generic, encouraging staff to accumulate academic credit as they work towards a Diploma, Degree or Post Graduate
qualification in health care.
The SHS library remains the centre within the GHA for information storage and retrieval. It provides expert assistance to staff as well as supporting the teaching, learning and research activity within SHS and the GHA. There is ongoing investment in the electronic databases as the Library advances with the use of new technologies. The physical collection also provides our users
with material to support them in their work.
Significant events The Enrolled Nurse programme of study has been extended from one year to eighteen months, this allows further acquisition of skills and the theory required to underpin their practice. The first ever cohort of BSc/BSc (Hons) Nursing (Adult) students graduated in September 2015 and this was a landmark event for Gibraltar. Eleven students graduated
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receiving their Degree in a graduation ceremony with dignitaries and distinguished guests from Kingston University London and St George’s University of London. Another milestone in the history of the SHS was that nine members of staff from the GHA received a Dip/BSc in Health Care Practice from St George’s University of London and Kingston University London.
Fourteen Enrolled Nurses, the first in Gibraltar, received their QCF level 3 award along with twenty four Health Care Assistants who also received the Health and Social Care QCF level 2 award. Four staff were awarded the A1 assessors qualification. Twenty two members of staff received the Extended Diploma QCF level 5 Diploma in Management and Leadership award at the same ceremony. These awards and the ceremonies that accompany them demonstrate due recognition of the dedication and commitment staff make towards enhancing the patient experience.
The first European Men’s Health forum Conference “Men’s Health and Primary Care, Improving Access and Outcomes in Gibraltar” was held in May 2015. This was a resounding success with over 30 attendees from a wide range of settings, including
general practice, pharmacy, public health, education, the armed forces and patient groups.
During 2015, the SHS became an Associate
Campus of the University of Gibraltar.
FutureThe SHS is steadfast in its desire to be able to respond to the needs of the people of Gibraltar through the provision of high quality, fit for purpose and contemporary healthcare education. It will continue to provide programmes of study at undergraduate level as well as postgraduate Masters level.
The GHA will continue to invest in the development of a contemporary multi-skills laboratory which will enable staff and students to work in a state of the art simulation environment. The re configuration and re-equipping of the computer suite will provide benefit for all GHA staff.
The SHS is committed to being the best provider of health care education within the region, strengthening our current provision and ensuring the development needs of the staff within the GHA are met.
10. MANAGEMENT
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10.1 SPONSORED PATIENTS
The role of this department is to provide service to patient and escorts/families to tertiary care centres outside Gibraltar.
The service offered by the department is to provide to both external and internal customers. External customers are patient/ families and hospitals abroad mostly in the United Kingdom and Spain. Sponsored Patients also provide a service to internal departments such as the Critical Care Unit and hospital wards in order to carry out their tasks such as organising In-patient transfers to other centres. The department also work closely with the GHA Accounts section for the preparation of payment of invoices from the various companies.
In November 2014, the department was provided with a new Computer System which has facilitated the inputting of patient data. It is a fast and effective system. All members of staff had an input and worked closely with the Information Technology
Department to make the system quick, accurate and user friendly.
During July 2015, the department developed contracts with various hospital accommodation centres allowing the department to book directly for patients if they so wish. This has proved beneficial for patients by removing pressures of having to find their own accommodation at a stressful time in their lives. The feedback on this new initiative has been positive. The number of people opting to continue with Means Testing Assessments has improved due to allowances being increased.
Also in July 2015, the ‘three week’ rule was abolished. Previously, patients had to remain in UK if they had an appointment within three weeks. The department can now fly people back to Gibraltar providing the time limit of the next appointment is reasonable. Patients over the age of 65 and those under 18 can now also request two escorts as opposed to just the one, based on individual cases and at the discretion of the Referring Directors.
10.2 HUMAN RESOURCES
OverviewThe Human Resources Department is dedicated to the recruitment, selection and retention of staff for all GHA departments. The department is continually assessing and developing its processes with the aim of improving the quality of the service provided for both internal and external customers.
RecruitmentRecruitment activity remained constantly high during 2014 and 2015, more so during the final months of 2014 and early 2015 with the recruitment of the additional staff for Ocean Views. Recruitment commenced in October 2014 with interviews carried out both locally and in the UK during the months of November and December. Appointees took up their posts in January 2015 in time for the scheduled opening of the new mental health facility.
Three significant appointments were made
in January 2014. Mr Darion Figueredo was appointed Unit General Manager – Hospital Services, Mr Chris Chipolina was appointed Unit General Manager – Mental Health and Mr Adam Wink was appointed Unit General Manager – Primary Care. These new posts are part of the senior management re-structure and are pivotal in the GHA’s commitment to sharpen its focus on the service delivery to patients. Amongst other responsibilities, the UGMs are accountable for the day to day management of services, implementation of strategy, clinical and corporate governance, financial management and performance monitoring.
As at 31st December 2015 there were a total of 1034 employees and the chart in the Appendix shows the distribution of personnel throughout the various staffing groups.
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10.3 DEVELOPMENTSDepartment reconfiguration
During 2014 the department carried out a review of its main functions and as a result embarked on a process of reconfiguration, with responsibilities and processes being modified with the aim of improving the overall service to both its internal and external customers.
The re-training of Human Resources staff commenced in February 2015 and relocation of workstations within the department was completed in August 2015, with the new reconfiguration fully functional by 1st September 2015.
As a result the Human Resources team has been split into three separate groups each with full responsibility for specific staffing groups, as follows:
Team 1 - Nursing Grades
Team 2 - Medical, Dental & Ambulance Grades
Team 3 - Allied Health Professionals, Administrative, Industrial & IT Grades
This reconfiguration gives the department greater flexibility when the need to cover absences in the department arises.
Policies A number of Human Resources related policies were introduced during 2014 and 2015.
Drug, Alcohol & Substance Misuse PolicyThis policy was introduced in December 2014 and establishes the responsibilities and principles behind the GHA’s approach to managing the misuse of drugs, alcohol or other substances by employees. This policy is intended to promote the general well-being of all employees and to avoid unnecessary illness, absences and accidents caused by drugs, alcohol and substance misuse. It is also intended to improve work performance
and to provide a working environment that ensures as far as possible, the health and safety of all employees, patients and visitors.
Exit Interview PolicyThis policy has been developed in order to establish an effective exit procedure for employees leaving the organisation. It will give individuals the opportunity to provide feedback on their perceptions of the GHA as an employer and allows the organisation to gather valuable information that may be used in modifying and developing our recruitment and retention strategies. This policy was introduced in July 2015.
Equality & Diversity PolicyThe Equality & Diversity Policy was introduced in July 2015 and has been developed in order to provide a framework to ensure that all the GHA’s employment policies, procedures and guidelines reflect and reinforce the organisation’s commitment to equality and diversity in the workplace. All policies will now be assessed by means of an Equality Impact Assessment Tool.
Corporate Induction PolicyThe underlying objective of this policy, introduced in July 2015, is to ensure that all new staff starting in whatever grade or discipline undertakes a structured and comprehensive induction that will enable them to provide a safe and efficient service within their area.
Departmental Induction Policy (Medical Staff)This policy was introduced in July 2015 and its objective is to ensure that all new medical staff starting in whatever grade or discipline undertakes a structured and comprehensive induction that will enable them to provide a safe and efficient service within their specialist area.
Students Careers FairThe Human Resources Department successfully co-ordinated the GHA’s participation at the bi-annual Students
Careers Fair. The event took place on Tuesday 24th February 2015 and as expected, the GHA’s stand proved extremely popular with visitors as it was a great opportunity for both students and parents to interact with a wide cross-section of healthcare professionals on the day. Representatives from practically every department in the organisation were present assisting with queries relating to training, job opportunities and career pathways.
Workforce PlanningThe Department continues to liaise closely with department heads and the Department of Education and Training with the aim of ensuring that there is a supply of qualified and, where necessary, appropriately experienced local applicants for all clinical posts, with the aim of reducing reliance on overseas contract staff.
Human Resources staff, along with representatives from other areas in the organisation, continues to visit local schools with the aim of promoting careers in healthcare and future employment opportunities in the GHA.
Training
Foundation Level Certificate in Human Resource PracticeIn 2014, two members of the HR team commenced a nine month training programme in the Foundation Level Certificate in Human Resource Practice (Level 3). This qualification provides a firm foundation in all areas of HR, as well as an understanding of HR in an organisational context.
Employee Investigations Law & PracticeThree HR staff members attended a course on employee investigations in the UK with the intention of disseminating the learning outcomes to others in the department and the organisation through structured presentations. The presentations will provide an understanding of the legal and best
practice requirements necessary to conduct employee investigations and the techniques required of the investigators.
NHS Employers Workforce Leaders’ SummitThe Director of Human Resources was invited and participated in the NHS Employers Workforce Summit, held at the ACC Liverpool. The summit gave participants the opportunity to discuss strategic workforce priorities.
NHS Confederation Annual Conference & Exhibition 2015Following on from the Leaders’ Summit, the Director of Human Resources attended the NHS Confederation Annual Conference & Exhibition. This conference is the largest meeting of senior health and care leaders in the UK. The experience was highly positive as it was extremely valuable to network with delegates and various HR professionals, during and after conference, in order to discuss common challenges and potential solutions face-to-face.
STAFF AWARDSSince its inception in 2007 the Staff Awards Programme has been growing in popularity and a very well attended 7th event took place in November 2014. A total of 106 individual nominations covering 63 separate staff and departments were received for consideration by the Staff Awards Committee.
The Director of Human Resources, assisted by members of the Staff Awards Committee, presented the Staff Awards Ceremony, whilst the Minister for Health, together with the Chief Executive and representatives from the main sponsors.
Awards were presented to the winners in each category, as follows:
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Qualified Nurse of the Year Susan Chappory (Enrolled Nurse)
Nursing Assistant/Auxiliary Nurse of the Year Desiree Castle (Nursing Assistant)
Doctor/Dentist of the Year Krishna Rawal (General Practitioner)
Allied Health Professional/Healthcare Scientist of the Year Michelle Brown (Head Orthoptist)
Innovation Award Justin McNiece (Electrical Health Technician)
Support Services Employee of the Year - Frontline Sigurd Haveland (Paramedic)
Support Services Employee of the Year - Behind the Scenes Noelle Reoch (GHA Clerk)
Ward/Department of the Year Critical Care Unit
Employee of the Year Steven Mascarenhas & Francis Mauro (Messengers)
The GHA is deeply grateful for the sponsors continued support and generosity towards this initiative.
10.4 CORPORATE SERVICES
Records Management The Medical Records Department strives to provide an effective and efficient service in the management of paper based recorded patient information which represents the systematic documentation of a single person’s
medical history and care within the GHA.
The objectives of the Medical Records Department are as follows:
• To ensure that the right record, for the right patient is available in the right place at the right time.
• To ensure that the medical record is completed by all professionals in a manner consistent with their expected professional standard of practice.
• To ensure records are stored safely and securely and in a manner that protects confidentiality.
• To ensure the correct disposal of medical records.
• To enable patients who have a right of access to their records and wish to do so.
Following the relocation of the department to accommodate a bigger library and further to the initial file grooming, the Gibraltar Health Authority again contracted with a service provider to complete the file grooming and tagging exercise. The enhanced tagging now incorporates the UPI, (Unique Patient Identifier) number and RFID chips. The tracking system has also been upgraded and now allows tracking to a specific area within the Medical Records library.
With the introduction of new technology and practices, the department now includes a networked patient database, file tracking software and mobile barcode readers.
The Records Department continues to support all clinics in the appointments process and is also responsible for booking clinics for all visiting specialties.
Front of House
Administration A new team of GHA Clerks have been recruited to provide a 24 hour administrative support to the Accident & Emergency Department. Although the primary role of the team is to provide a comprehensive administrative support to the department, including manning the reception desk, duties also include afterhours service for retrieval of patients records, registration of unregistered patients and assessing non-entitled patients attending A&E. Efficiencies responding to the public and providing patient records, registration and accounts function has been improved due to the quick response of having staff on site. There has also been a substantive saving in overtime costs considering that staff
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previously on on-call duties had to attend when recalled in order to cover these roles.
Domestic ServicesThe Domestic Services Department are responsible for the following services:
• Domestic cleaning
• Labouring services
• Laundry Services, including Linen Distribution
• Seamstress Service
• Refuse and Clinical Waste collection
The new management structure now includes a Deputy Manager and will shortly introduce dedicated Supervisor posts which have been approved to cover all sites within the organization. This new structure will provide an improved and pro-active approach to manage the operational requirements of the Gibraltar Health Authority.
Improvements and achievements introduced during 2014/15 include the following:
Completion of soft furnishings for Ocean Views by our Seamstress department following the agreed colour scheme for each floor.
Following best practice and in liaison with the Infection Control Officers the department piloted and introduced disposable privacy curtains in all clinical areas. Disposable curtains eliminate both the cost and environmental impact of laundering conventional curtains. The curtains are durable and have shown that they can stay hanging for a year or more, however the department assesses the frequency at which the curtains should be changed in different areas. Each curtain has a self-audit label so that it can easily be audited when it was last changed. Disposable curtains also comply with the same fire retardancy standard as conventional curtains and are manufactured from a durable, disposable, and completely
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recyclable polypropylene fabric which inhibits bacteria growth.
The management and storage of materials has been solely devolved to this department. Top up service for cleaning products has been successfully introduced.
Minor WorksThe Minor Works team provides maintenance and up keep to all areas across the organization.
During 2013/14 the team have been involved in major refurbishment works in the Primary Care Centre and Community Mental Health department.
Improvements and new works included the following:
• New maintenance programme introduced for the systematic overhaul of all wards and departments.
• Refurbishment of the Medical
• Investigation Unit, Phlebotomy Department, Operating Theatres and all wards.
• Expansion of Pharmacy Department.
• The refurbishment of all ensuite bathrooms within the wards.
• New reinforced guttering
• A temporary Ebola Unit created
Refurbishment of all food & beverage bays in wards to accommodate the new bulk food service.
Catering The new Catering Facility commenced operation on 10th October 2015. A wide range of professionals were involved in this project and without them this important achievement would have not been completed as smoothly as it was.
The initial feedback has been very positive. The department offers a choice at point of consumption which is an improvement from the previous meal service.
New Initiatives & Improvements
Pan Dulce Since the move from the old St Bernard’s Hospital, patients have not had the traditional pan dulce but now every Christmas this will now be enjoyed by patients.
New Menu for St Bernadette’s. A new specific menu to meet the requirements of St Bernadette’s Centre has been developed and implemented.
Choice at point of consumption Patients can now choose between four main courses and even order something different if desired.
Food QualityFood is of a better quality in general and temperature control has been improved. All food provided to wards at St Bernard`s are monitored for temperature and this is recorded.
Environmental improvements
The new catering facility has led to environmental improvements such as;
•Water and electricity consumption being reduced by at least 30% reduction in the use of batteries and carbon emissions
•Eco-friendly sandwich container packs have been introduced.
10.5 INFORMATION MANAGEMENT AND TECHNOLOGY The GHA’s Information Management & Technology (IM&T) department maintains systems and networks across 5 geographically separated sites all of which are connected via fibre cable or wireless network links. During the course of 2014/2015 the department went through a period of substantial change. A new Director of IM&T was appointed on
30th June 2014 and this promotion resulted in the promotion and additional recruitment of staff to the department. Additionally, the procurement and implementation of the EMIS Health Electronic Patient Record (EPR) system has required much involvement from the team in both implementation and support.
There are currently 100 servers, 30% of which are virtualized, approximately 650 PCs and over 70 centralised networked printers. A range of clinical systems currently in place consist of the Electronic Patient Record, Radiology, Pathology, CCU patient monitoring, Dental Xray, Endoscopy, Colorectal Screening, blood bank control and many more.
The department continuously monitors all of our systems across all of the sites 24 hours a day, 7 days a week. Warnings and alerts are sent straight to the helpdesk and duty engineer so that problems are resolved swiftly and effectively ensuring that problems encountered are kept to a minimum and sometimes alleviated before the end user even realises there was an issue in the first place.
The IMT helpdesk is now handling between 600 and 700 calls a month together with approximately 200 direct support ticket requests with totals approaching 900 support requests per month. This signifies a 50% increase over the previous 2 years and reflects a continued increase in the number of IT systems being introduced as well as the GHAs ever increasing reliance on those IT systems, especially since the implementation of the EPR system in June 2015.
IM&T staff members are on a constant programme of Continuing Professional Development to remain up to date with the latest technological developments and standards.
There has been the need to invest in additional Server hardware to facilitate new systems that have been implemented over the course of the two years.
Many of the major projects or work streams
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undertaken over the two years are:
• EPR Project – upgrade of existing PCs and expansion/development of IT infrastructure to accommodate the project
• New Mental Health Facility- installation and commissioning of all IT hardware.
• Community Mental Health project – upgrade of all IT equipment and installation of additional hardware
• Hospital Wifi Installation - completed and to be commissioned in 2016
• Upgrade of PCs from Windows XP to Windows 7 – 95% complete. Final 5% to be completed early in 2016.
• Digital Dictation (Bighand) deployed across the whole of the Hospital and Primary Care Centre
• Intranet Site redesigned and due to be launched early in 2016
• Records tracking software upgrade from Filetracker to Filetrail completed in 2014
• All servers relocated to the new purpose built hospital data centre in 2014
• Chemotherapy suite IT infrastructure complete for opening in 2016
• Upgrade of aging CCTV infrastructure complete. Camera replacement planned for early 2016
• In house development & launch of completely new tailor made Sponsored Patients System
• In house developed Human Resources System – work started in 2015 to continue into 2016
• In house developed Hospital stores inventory & stock control system
• In house developed screening software primarily for Colorectal and AAA Screening programmes
• EMIS Health EPR system- collaboration and integration of existing in house systems not covered by the project together with works streams enabling the transfer from the in-house systems to the new Emis Health suite of applications
10.6 ELECTRONIC PATIENT RECORDIn 2014, the Gibraltar Health Authority (GHA) embarked on arguably this organisation’s most important quality improvement initiative, the Electronic Patient Record Programme. The aim was to deliver on the Government’s 2011 Manifesto Commitment on ‘the computerisation of all patient notes … targeted at clinical/patient need’. The brevity of this statement does not capture the potential impact of this programme in transforming healthcare nor consequentially the socio-technical challenge that the organisation faced in its implementation. The quality of the care is determined by the quality of an organisation’s communication
and it is this information and its flow that governs all its processes and predicates clinical outcomes. An Integrated EPR System will help the organisation improve the quality of the service it provides, making it safer, more patient-centred, effective, efficient and transparent. It will underpin all its clinical care and patient administration but also inform professional, regulatory and statutory requirements.
The programme commenced with the Competitive Dialogue Tender Process and this was the first of its time that the Government of Gibraltar (GoG) had used this demanding and complex tender process. This required collaborative working between several GoG departments and external agencies. However, the most significant feature was the engagement of key stakeholders in this process i.e. frontline clinical and non-clinical staff. They were tasked with the responsibility of evaluating the products, short listing the suppliers and
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making the final recommendation on the preferred supplier. This required that they participate in the scripted demonstrations and attend site visits to view the products in the live environment. Their involvement has been central to the initial success of the programme and their contribution cannot be underestimated. Four suppliers responded to the Invitation to Tender and two suppliers were asked to submit their Best and Final Offer (BAFO). EMIS Health was selected as the preferred bidder and the contract signed in September 2014.
In this agreement the supplier would create the backbone of the integrated electronic patient record (EPR) by developing their core products and contracting previously agreed third suppliers for the provision of best of breed products for specialist departments, e.g. critical care and maternity. The initial timeline for completion of the full programme was three years with the project split into three main phases: Phase 1, Phase 2 and Phase 3.
The introductory Phase 1 resulted in the introduction of Patient Master Index, Primary Care (Emis Web) and Accident and Emergency Department (Symphony) Electronic Health Records. During this stage, the staff from these areas i.e. doctors, nurses, AHPs and administrative staff were actively involved in the programme. In conjunction with the EPR Project / Deputy Project managers they led or assisted in the configuration, development, training and testing of the systems. This Phase was successfully completed on the 24th June 2015. The outstanding item that required continued development into Phase 2 has been the dispensing and reimbursement solution for the community pharmacies. This is due to be completed in 2016.
Some of the benefits include;
• there is no longer need for cards in Accident and Emergency Department
• the ability to view previous attendances to these departments
• clinical records are not being lost
• multiple users are able to view clinical records at any one time
• clinical records can be viewed from multiple locations
• prescribing alerts
This led to the commencement of Phase 2 of the programme and the planning for this took several months with approval of the Programme Initiation Document by the EPR Board in January 2016. However the unplanned delay to this stage has allowed staff to be appropriately supported during the bedding in of the Phase 1 EPR solution and assisted in resolving all outstanding issues that have become apparent since going live. It is planned that Phase 2 will result in the implementation of Secondary Care and Mental Health Patient Administration Systems (PAS), the core Secondary Care Clinical Documentation (i.e. General Medical and Surgical Inpatient Wards and Secondary Care Outpatient Clinics) and four non-core departmental systems: Maternity, Critical Care, Pharmacy and Theatres.
The introduction of the different systems in Phase 2 will be modular and have a phased approach. The final stage, Phase 3 will build on the secondary care core elements through the inclusion of Mental Health acute and community clinical systems and an integrated electronic prescription and medicines administration (ePMA) system. The decision will be made at this stage as to which other noncore systems will be integrated into the final solution and this is planned for early 2018.
This journey has not been painless and as with all change programmes these are demanding and difficult for most staff. However GHA staff have been exceptional in the way they have managed the very complex transition in such a short timeframe.
10.7 ESTATES AND CLINICAL ENGINEERING The Estates & Clinical Engineering Directorate is responsible for the management and development of the GHA’s overall Estates strategy and engineering support. The GHA’s estate is spread across multiple sites that include St. Bernard’s Hospital, Primary Care Centre, Ocean Views Psychiatric Unit, CMHT Unit and the Catering Facility. There is also an increasing amount of equipment maintained for patients in the community.
The Directorate’s workforce is comprised of Staff attached to the GHA from the Gibraltar Electrical Authority (GEA) and directly employed GHA staff. They cover the Clinical, Electrical, Mechanical Engineering and Building Management Systems responsibilities of the GHA Estate.
The management team is responsible for estates planning, engineering systems resilience & business continuity, lifecycle planning, space planning, utilities
management, major works, contracts management, financial control, backlog maintenance and statutory compliance.
Directorate StrategyIn keeping with the GHA’s new 3 year Strategic Plan and following GHA Board approval, the Directorate has identified the following 8 work streams which will be critical to ensure the directorate is ready to meet the challenges posed by an increasingly flexible and technology based healthcare system. The directorate will therefore address these through an implementation plan. The eight core themes are outlined below:
1. Workforce Plan ( Succession Planning, Recruitment, H&S, Training, Specialisation, CPD, Apprentices & Graduates).
2. Resilience & Business Continuity Plan.
3. Medical Devices Management Strategy. (MHRA Compliant).
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4. Lifecycle Replacement Plan for Medical Devices, Plant & Infrastructure.
5. Energy Conservation Plan.
6. Departmental Quality Plan. (ISO 9001:2008).
7. Audit System, (Internal & External).
8. Computer Aided Facilities Management System (CAFM).
Staff DevelopmentDuring the period covered by this report, Technical staff attended a number of courses both locally and abroad reflecting the department’s continued programme of staff development. These included;
• Servicing Anaesthesia & Ventilation Equipment.
• Quality Assurance ISO 9001.
• SR Hotline H-90 fluid warmers course.
• Manual Handling Courses.
• Fire Training.
• Risk assessment Workshops.
• Medical Gases Pipeline Systems - Competent Persons (MGPS) Refresher-HTM 02
• Medical Gases Pipeline Systems - Authorised Persons (MGPS) Refresher-HTM 02
• Electrical Technicians conversion course.
• Surgical Tables (T20+ &T30+) Service Training course
• CPD sessions on Quality Assurance, Medical Gases, Electrical Distribution and HVAC Systems.
Apprentice Training Scheme.The department is participating in the development of apprentices. Four mechanical apprentices have been attached to the GHA’s Mechanical Section as part of a 3 year training programme. They will be
completing their apprenticeship during the first quarter of 2016. These programmes are of considerable value in preparing young engineers for succession planning within the Directorate.
Capital Development Programme 2014 & 2015The Directorate has been able to deliver on an ambitious capital development programme made possible through the GHA’s Improvement & Development Funding allocation during both 2014 & 2015. Many of these projects have been carried out by In-House staff and have been successfully delivered with the participation and collaboration of staff from many departments including essential input from Clinicians. The following list highlights some of the major initiatives carried out during this reporting period.
Capital Projects delivered during 2014Installation of new public lift at St. Bernard’s Hospital.
• Redevelopment of the Endoscopy Suite to facilitate the Colon Cancer Screening programme.
• Relocation of the Liquefied Oxygen Tanks facility.
• Upgrade to St. Bernard’s Hospital Fire Damper Systems.
• Complete redevelopment & expansion of the Community Mental Health Facility.
• New clinics and Boardroom at the Primary Care Centre.
• New Dermatology Suite at the Primary Care Centre.
• Upgrading of the UPS system at Endoscopy.
• Upgrading of the UPS system at the Radiology Viewing Area.
• New Cardiac Alert system installed at the Primary Care Centre.
Capital Projects delivered during 2015• New Escalators at the entrance to St. Bernard’s Hospital.
• Installation and Commissioning of the new 128 Slice CT Scanner.
• Upgrading of the Hospital Signage.
• New Improved Surgical lighting at General Theatres.
• New Surgical Microscope for Ophthalmic Theatres.
• New Large Porous Load Autoclave for the Central Sterilisation Services Unit.
• New Emergency back-up generator providing 100% resilience to Primary Care.
• New Dental clinic at the Primary Care Centre.
• New Cardio Vascular ultrasound for the Medical Investigations unit.
• Upgrade to St. Bernard’s Hospital Fire Alarm System.
• Commencement of works to new chemotherapy unit.
• Design works for the expansion of Accident & Emergency Department.
• New Domestic Services Administration offices.
Energy Efficiency ProgrammeGiven that the GHA is a large consumer of energy, the Directorate takes Energy Efficiency very seriously. Our Technical Staff continue to be engaged with various initiatives to monitor and improve building energy use across the GHA Estate. Some of these initiatives include:
• Introduction of LED lighting in all new developments.
• Smart Metering.
• Heat recovery from Air Conditioning systems.
• Assisting with the Design of the new
Solar Thermal System.
• Close Control and regulation of HVAC systems.
It is very gratifying and encouraging to report that the department’s sustained commitment with respect to energy efficiency has been formally recognised following an exhaustive energy use audit carried out by an independent energy assessment team.
St. Bernard’s HospitalSt. Bernard’s Hospital has been awarded an “ A” rating for Energy Efficiency.
St. Bernard’s Hospital has been awarded an “ A” rating for Environmental Impact.
Ocean ViewsOcean Views Main Block C has been awarded an “A” rating for Energy Efficiency.
Ocean Views Main Block C has been awarded an “A” rating for Environmental Impact .
Ocean Views Main Block D has been awarded an “B” rating for Energy Efficiency.
Ocean Views Main Block D has been awarded an “B” rating for Environmental Impact.
Lifecycle PlanningAs can be appreciated from the report, the Directorate continues to support Healthcare professionals with improvement projects across all facilities. There is also considerable work involved in planning and executing the Health Authorities lifecycle replacement plans.
The Clinical Directorate’s workload is directly linked to the number of assets in use and the age of the installed plant and equipment. Both these factors are on the increase and a sustained commitment to lifecycle planning is essential.
This is particularly important in the area of Medical devices, given the large asset inventory on books and the critical nature of these devices. As the new hospital moves into
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its 12th year of operation, there is an increasing number of assets under management that are moving into the last phase of their recommended lifecycles. The department works diligently to maximise the benefits of the allocated resources in order to mitigate clinical, operational as well as financial risks.
10.8 FINANCE & PROCUREMENT The total value of the accounts generated for the GHA, for the Financial Year ended 31st March 2015 was around £108.2m against an approved budget of around £101.6m. Detailed analysis of 2014/2015 expenditure and comparative figures going back to Financial Year 2010/2011 follow the report.
Expenditure shows around £6.6m deficit over approved budget, but this needs to be considered in conjunction with budgeted revenue for 14/15 performing positively by around £3.7m against an approved budget of £49.9m.
Actual 14/15 revenue was around £53.6m.
General DevelopmentsThe Department of Finance continues to strive to improve processes that will deliver better budgetary control and financial balance within operation of a devolved budgetary system.
Co-ordinating and improving the GHA’s estimate process is one of the main Finance functions. This continues year on year.
The revised MOD Secondary Health Care agreement has now been operating successfully since July 2014 delivering benefits for both the MOD and the GHA.
PayrollThe Payroll section continues to provide all payroll support and runs the payroll operation of over 1500 monthly salaries comprising salaries of all GHA approved complement posts, contract posts, locum cover and around 260 salaries for Care Agency nursing staff.
Payroll processing, the primary role of the
section is subject to very strict deadline routines governed by the Government’s Treasury Department that need to be adhered to in order to ensure the delivery of monthly payroll on 27th of every month.
Account and Payments
AccountsPhysical revenue collection within the GHA and establishing patient entitlement to be able to invoice costs where appropriate remains the main role of the Accounts Department with patients accessing care at St Bernard’s Hospital mainly via Accident and Emergency and the Ophthalmic Department.
Accounts officers operate a 24/7 on call service to assist in establishing health care entitlement.
Accounts officers as part of their role liaise closely with a large number of GHA Departments.
PaymentsThe Payments section’s main function remains reconciliation with Treasury and preparation and processing of all documentation, in lines with accounting instructions, as required by the Treasury Department to settle any payments that need to be made by the GHA to external suppliers or clients.
This section also has to adhere to very strict daily and monthly deadlines governed by the Governments Treasury Department to ensure the timely settlement of all GHA payments.
Operating with the Great Plains accounting software package the section keeps the main source of financial data for the organization to assist all devolved main budget holders/Senior Managers in analysing and controlling their elements of the GHA’s recurrent and capital expenditure throughout the financial year.
Over 5,000 payments are prepared by the
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team annually with the GHA’s annual budget apportioned between around 60 internal devolved expenditure accounts.
Procurement and Stores
ProcurementProcurement is responsible for the sourcing of any goods/items required by the organisation.
A major role of Procurement is ensuring value for money from suppliers in lines with Procurement regulations.
The Procurement section places replenishment orders for over 1,500 items annually kept as stock in GHA Central stores, as well as other more specific orders of non-stock items for Department/Wards, Primary Care Centre, Ocean Views, Catering and Community Mental Health.
StoresThe core roles of the stores team are;
• The upkeep and running of the main stores at St Bernard’s Hospital and other GHA external stores
• the replenishment of stock items to all GHA wards
• liaison with Procurement section to ensure minimum quantities of all stock items are available in the GHA
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