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Health Matters 2011Gibraltar Health Authority

Health Matters 2011 | 3

In this issue...

Health Matters 2011Gibraltar Health Authority

1. Public Health 8

1.1 VITAL STATISTICS 9

1.2 INFECTIOUS DISEASES 12

1.3 IMMUNISATION 15

1.4 CANCER 15

1.5 ENVIRONMENTAL PUBLIC HEALTH 16

1.6 HEALTH PROMOTION 16

1.7 PUBLIC ANALYST REPORT 18

2. Chronic Disease Management 19

2.1 DIABETES SERVICES 20

3. Primary Care Services 22

3.1 PRIMARY CARE CENTRE 23

3.2 PRIMARY CARE NURSING 24

3.3 DENTAL SERVICES REPORT 26

3.4 GENERAL PRACTITIONERS 27

4. Secondary Care Services 29

4.1 DEPARTMENT OF MEDICINE 30

4.2 AMBULANCE SERVICE 31

4.3 ACCIDENT AND EMERGENCY 33

4.4 OPHTHALMOLOGY SERVICES 34

4.5 ORTHOPTIC DEPARTMENT 35

4.6 AUDIOLOGY 36

4.7 MENTAL HEALTH SERVICES 37

4.8 BED MANAGEMENT 40

4.9 MEDICAL EXECUTIVE 41

5. Diagnostic Services 43

5.1 PATHOLOGY 44

5.2 DIAGNOSTIC IMAGING SERVICES 46

6. Therapy Services 51

6.1 PHYSIOTHERAPY SERVICES 52

6.2 OCCUPATIONAL THERAPY 54

6.3 SPEECH AND LANGUAGE THERAPY 56

6.4 NUTRITION AND DIETETICS 57

6.5 PHARMACY 58

7. Nursing 59

7.1 STRATEGIC CHANGE 60

7.2 MEDICAL NURSING 65

7.3 SURGICAL NURSING 67

8. School of Health Studies 69

8.1 OVERVIEW 70

8.2 DEVELOPMENTS 70

9. Management 72

9.1 SPONSORED PATIENTS 73

9.2 PATIENT ADVICE AND COMPLAINTS OFFICE 73

9.3 HUMAN RESOURCES 74

9.4 CORPORATE SERVICES 77

9.5 INFORMATION MANAGEMENT AND TECHNOLOGY 80

9.6 ESTATES AND CLINICAL ENGINEERING 82

9.7 FINANCE & PROCUREMENT 84

10. Appendix 86

ACKNOWLEDGEMENTS 106

4 | Health Matters 2011

This report is the first one that I introduce as Minister for Health, and is significant as it covers a year, which for the most part was under another administration of another social philosophy and another Minister.

But it is the essence of the public service that the professionals it employs will do of their best, regardless of the political government, and this report is a tribute to the professionals and not to politics. Therefore, apart from statistical facts, it highlights mainly the positive fruits of the labours of my now colleagues in the GHA.

It is particularly moving for me to be writing this report. My years as Hospitals Manager and General Manager in the late 1980s and early 1990s were among the most challenging and fulfilling of my life. I thoroughly enjoyed my years at the GHA then and was immersed in a spirit of teamwork that I have never experienced since. Never in a million years, when I left to follow my professional career elsewhere, nor during the fifteen years I was a Board member, did I think I would return as Minister and Chairman of the Authority I had helped create.

Any fundamental change in administration has clearly got to bring about change. But that change has to be managed and tempered, respecting the good in the old and moulding it towards the greater good in the new. This process has started and, I hope, by the time I write my foreword to the next annual report, will have borne the fruits of improvement in the way we do things, in our delivery of care, and in the wellbeing of our patients and clients.

We have in the Health Authority, a tremendous responsibility to use what are significant resources, in the most efficient and effective way possible, exploring new possibilities in healthcare, finding and accepting new challenges and doing that extra bit more, even beyond the call of duty, to improve the service. We must work together as a team, between professions and with outside agencies, respecting professional boundaries but unafraid of overlap, when exemplary care of our patients is to be the outcome.

It is important that the Health Authority should be accountable to the people and this Annual Report is a way of placing on record much of what we do.

I am sure that you will find it interesting.

With my very best wishes

(October 2012)

Foreword by the Minister for Health and Environment Dr. John Cortes MBE MP


I am delighted to introduce the Gibraltar Health Authority’s Annual Report covering the year 2011. These reports are now familiar events, whether published singly or in clusters of a few years, and provide an opportunity for the public to understand and appreciate the huge and varied work that is being carried out on their behalf and for their benefit.As in previous years, the Report commences with a snapshot of the health of the Gibraltar population and then proceeds to chronicle significant events that have collectively shaped the health services and delivered health care to the people.The health of the Gibraltar population is one of which we can be reasonably proud. In many key indicators on which the public health of a nation is judged, such as child welfare, infectious disease control, immunisation programmes, environmental quality, life expectancy, etc., Gibraltar emerges among the healthier nations of the world. The Report offers many examples of how health professionals are striving to promote health, prevent suffering and prolong life. One of the most significant achievements in 2011 was the opening of the Stop Smoking service, the first of its kind in Gibraltar, which helps smokers to quit using scientifically proven methods. The “Day at the Dentist” initiative aims to detect early disease in children of primary school age as well as teach them good hygiene early in life. The DESMOND programme aims to teach adults with newly diagnosed Diabetes how to look after themselves and remain healthy. These are just a few of the health improving initiatives commenced this year.The GHA continues to invest in up to date technology. The new Optical Coherence Tomograph enables doctors to see 3-D images of the eye and is invaluable for diseases like Advanced Macular Degeneration and Glaucoma. The Radiology Information and Picture Archiving systems allow x-ray images to be captured digitally, stored and delivered instantly to any screen at high resolution. New technology enables Cardiac arrest emergency calls to be sent directly to doctors’ pagers, saving valuable time.Investment in staff is a hallmark of good organisations. Staff appointments in 2011 included eight consultant doctors, a Diabetes Nurse Specialist exclusively for

children and a Public Analyst. In line with longstanding GHA strategy, a locally trained Director of Nursing was appointed. The GHA has also continued to invest in staff learning through numerous staff development programmes. A significant event was the Nursing Conference, which included celebrity speakers like Amanda Waring, who gave powerful take-home messages for all those who care for older people. Emergency Medical Technicians were also trained to take advantage of a new law that enables them to administer life-saving medicines in emergencies.Despite these and many other achievements, there were also glimpses of challenges ahead. The birth rate continues to rise with 446 babies born this year, although the actual growth in the resident population remains modest. However, the increase in Casualty attendances from 24,857 (2001) to 34,824 (2011), growing at 3.5% each year, is a matter for concern. Similarly, out-patient attendances, GP consultations and demand for sponsored care all continue to rise. Against this backdrop, still only 54 out of the 120 beds in the hospital are available to use for admitting ill patients. Perhaps the most sobering finding is the relentless rise in cost of health care. The GHA expenditure in 2011 of £89.2 million was £9.3 million more than that in 2010. This represents a rise of 11.6% in one year and in fact, GHA expenditure has grown at almost 10% each year during the last 7 years. By contrast, the equivalent growth in the UK was just 2.2% each year. This is a challenge that will need to be confronted.However, on a more positive note, the number of complaints received by the GHA continues to fall, down to 144 this year, while the number of commendations received rose to 494.I would like to conclude by thanking all those who contributed to this report in the face of difficult deadlines and the editorial and production teams for their support in making it possible.I cannot end without paying a tribute to Dr. David McCutcheon, who has now left the service of the Authority and who always took a keen interest and delight in the compilation of the Annual Reports. Indeed much of this present report owes itself to his efforts in getting the material into shape.

Introduction by the Director of Public Health Dr. Vijay Kumar MBMS MSc FRCSEd FFPHM MBA


Health Matters 2011 | 9

1.1 VITAL STATISTICS

Population

The national decennial Census which had been held uninterrupted since 1871 (except for the war year 1941) failed to take place in 2011, as a result of which, only estimates can be given of the population in this report and the calculated ratios shown are likely to suffer from error due to the use of outdated denominators.

Population estimates published by the Government Statistics Office suggest that Gibraltar’s population is steadily growing in small amounts. The estimated population on 31st December of 2009 was 29,431, while that of 2010 was 29,441 and that of 2011 was 29,752. This represents a sharp increase of around 1.0% against the previous year, while the growth averaged over the last decade was around 0.69% per annum compounded. However, it should be emphasised that such calculations derived from estimates may not be wholly reliable.

Births

The number of births recorded in Gibraltar in 2011 was 446, which is a slight drop from the previous year (482 in 2010), but nevertheless in keeping with the rising trend in recent years. There were no stillbirths in 2011.

The crude birth rates calculated for the last five years were 12.6% (2007), 12.6% (2008), 14.1% (2009) 16.4% (2010) and 15.0% (2011). This recent trend of rising birth rates appears to be is in sharp contrast to the decade previous to this, throughout which the birth rates of the local population had been gradually declining.

It must be emphasised that these rates are, of course, calculated using population estimates rather than Census counts and the possibility of a statistical artefact caused by a simple unrecorded increase in the number of child-bearing women cannot be overruled. On the other hand, there is the interesting possibility that the fertility in Gibraltar

is really increasing, bucking the trends seen in most large European countries.

If this increase in birth rates is real, it however cannot be attributed to any alteration in societal norms, as the relative proportions of births in different age groups have remained stable for the last five years. It is also clear that births to foreign nationals are not responsible for this increase. The absolute number of births to other nationalities has in fact steadily fallen in recent years - 43 (2005), 32 (2007), 30 (2009) and 27 (2011) - while in the same period, the proportion of births to British or Gibraltarian nationals has steadily increased - 90% (2005), 92% (2007) 93% (2009) and 94% (2011).

Of the births, 26 were born to the British Forces sub-population. In past years, this sub-population accounted for around 8% of all births in Gibraltar, but in the last three years this has fallen to about 5%. This is actually due to increase in local births rather than a reduced birth rate in the Forces population.

The GHA Annual Report for 2005-2008 recorded a curious observation that while male births had absolutely predominated until 2002, since then, male and female births seemed to predominate in alternate years, with males predominating in odd years and females predominating in even years. Again, this curious see-saw trend continues, with males predominating at 55.1% (2011). It may be recalled that females previously predominated at 51.5% (2010) and males at 52.4% (2009).

All births took place in hospital, except for two home births, one each to the local and British Forces sub-populations.

The number of births to teenage mothers was 25, which is in keeping with the trends in the last few years. Again, one mother was aged only 15, while five mothers were aged 17. It is now well known that having children at such young ages can give rise to unsatisfactory health, psychological and social consequences and perhaps more targeted advice on planning pregnancies is needed.

Births in the local population have steadily increased over the last five years

1. Public Health

1 0 | Health Matters 2011

Health Matters 2011 | 1 1

The trend of increasing numbers of mothers at older ages continues. The proportion of mothers over the age of 35 seems to have settled at around 20% throughout the last ten years. However, the proportion of mothers aged 40 and over seems to be increasing in the last two years – in 2011 there were 20 mothers over 40 years (4.5% of all births), while similar figures for earlier years were 21 mothers (4.4% of all births) in 2010 and 13 mothers (3.1% of all births) in 2009. The oldest mother in 2011 was 46.

The proportions of babies born with birth weights below 2500g remain low, suggesting good general health status. In 2011, as in 2010, there were 21 (4.4%) low birth weight babies. The average weight continues to remain very stable, with 26% of all births falling within 5% of the mean weight of 3328 grams (7lb 6oz).

Deaths

Life expectancy in Gibraltar is good and continues to increase with the passing years in line with the best of European standards.

There were 233 deaths in the resident population in 2011, giving a crude death rate of 7.9, which is similar to that of recent years.

The mean age at death of males in the resident population continued to rise this year to 75.2 (2011) compared with previous years at 74.9 (2010) and 73.4 (2009), while that of females again dipped very slightly to 79.5 (2011) compared to the previous year 80.3 (2010) and to the average in the previous five years of 81.6. Although these small differences may not be statistically significant, they do suggest that the gap between males and females might be narrowing.

There were no deaths in infants or young persons. The age of the youngest person to die was 24.

As in previous years, the extent of “premature deaths” was calculated as an index of health in a population. Premature death is a loose concept

based on the belief that any person who dies at an age that is at least a full 10% below life expectancy might have been preventable. It should be emphasised that this is only a theoretical concept and that causes of death do not necessarily follow suit. In order to simplify calculations, all persons who died before the age of 70 were assumed here to be premature deaths.

Generally, the proportion of people who die prematurely in Gibraltar has remained stable, around 20% of all the deaths and the figure this year has remained true to this trend at 20.2%. In total, 47 persons died before their 70th birthday.

However, the marked and striking gender contrast noted in several previous years in this particular group, was remarkably absent. In the past, generally only half as many women as men died before their 70th birthday, but this year, 26 women and 25 men died before the age of 70, suggesting that here too the gender gap has narrowed.

In earlier reports, another measure of comparative premature mortality was also studied, the number of deaths in the 50-70 age group. It was reported that during 2009 and 2010 combined, only 12 women died between the ages of 50 and 70, as against 36 men, namely, three times as many. However, this year, 21 women and 18 men died in this age group, suggesting yet again a narrowing of the gender disparity.

The gender patterns for deaths in the over-70s also show the same reversal, although less strikingly. It used to be consistently the case for several years that more men died than women and that they died earlier. Typically, male death rates used to rise sharply from the late 50s, peaked in the late 70s and fall gradually thereafter, with very few men still alive in the 90s. On the other hand, the death rate for women usually did not rise until the 70s, peaked in the late 80s and then fell gradually. However, this year, quite surprisingly the mortality graphs for men and women have virtually run in parallel right until the 90s.

All these figures seem to suggest that the mortality patterns in women seem to have slightly worsened, while those of men has either remained stable or improved, thus reducing the gender gap.

One feature, however, has not changed and that is longevity, after the 90s. Women still substantially outlive men in this age group. In 2010, only 6 men and 20 women reached the 90s, and no man (but 1 woman) lived to be a centenarian. However, in 2011, 9 men and 32 women reached the 90s, while one man as well as one woman died centenarians.

Cancer is now firmly the class leader of the causes of death for five years running with 61 deaths (26.2%) attributable to it this year. However this year, the second place has been taken by Respiratory diseases with 56 (24%), pushing the leader of yesteryears Heart Disease into third place (19.3%). The trends in other causes of death

are more or less static.

Cancer is even more dominant as a cause of death in younger ages, accounting for 33.3% of all deaths in persons under 70 and this is in line with previous years: 33% (2009) and 37% (2010).

The top 6 cancers causing mortality have remained the same for many years, namely Lung, Colorectal, Stomach, Prostate, Pancreas and Breast. These together accounted for 48% of all cancers this year.

Lung Cancer continues to be the leading cause of cancer death, with 8 deaths this year (16% of all cancer deaths). The striking gender difference that has been pointed out in earlier reports still holds good, with more than 80% of Lung Cancer deaths occurring in men.

Over many years, these public health reports have consistently campaigned for progressive social

Male life expectancy appears to be improving

Cancer and respiratory diseases overtook heart disease as the leading cause of death

Births in Gibraltar continue to rise.



reforms to curb tobacco smoking in the community and health service initiatives to reduce its impact on the health of the population, as tobacco smoking is the most significant contributory cause of lung cancer and several other diseases. It is gratifying therefore to note that within the last twelve months, the Authority has set up a Stop Smoking service that uses medical advances to help smokers give up smoking and the Government has publicly committed itself to legislation prohibiting smoking in enclosed public places.

Colorectal cancer is the second largest cause of cancer deaths with 6 (14% of all cancer deaths). Most colorectal cancers are silent and by the time symptoms appear, such as blood in the stools, anaemia or pain, it is often too late. However, it is possible to detect the cancer in the early stages by means of tests, and the Authority is currently considering the possibility of a population screening programme. A small proportion of colorectal cancers occurs in families and such families have specialised programmes.

Breast Cancer remains the most common cause of cancer deaths in women, with 7 deaths this year, slightly more than the ten-year-average of 5.7, balancing the relative fall in the last two years. Breast cancer is also a cause of death at younger ages, with 6 out of the 7 deaths occurring in women under the age of 70, one of whom was aged only 50 years. It is hoped that the recently commenced Breast Cancer Screening programme will have a substantial impact, although such initiatives take about seven years to show measurable results.

There were 5 deaths due to cancer of the pancreas - which is strongly linked with long term alcohol consumption – a small excess over the ten-year-average of 3.2.

It had been noted in the reports for the past 6 years that deaths due to Respiratory diseases had been increasing at the rate of about 1-2% per annum and in 2011, this trend seems to be continuing. Of the 56 persons who died of these causes, 30 (53%) died

of pneumonia. Interestingly, the age distribution is quite uniform from the mid-50s to the mid-90s, contrary to the expectation that the risk might increase with age.

Infectious diseases were responsible for 19 deaths this year, similar to recent years, with 17 (2010) and 19 (2009), indicating a new steady state that is around double the average in previous years. However, the majority of these occurred in elderly persons and almost all were terminal septicaemias, suggesting that the apparent rise in the proportion of deaths from infectious diseases is not due to a resurgence of infections, but a secondary consequence of increased longevity.

This year, only 19 persons (8% of all deaths) had Diabetes listed as a contributory cause. However, it should be pointed out that diabetes is not always recorded on death certificates.

1.2 INFECTIOUS DISEASES

Laboratory confirmed infections

The total number of laboratory confirmed cases of infection fell this year to 197 cases, from the ten-year average of around 240.

The incidence of food-borne infections continues to fall dramatically over the years. There were 18 reported cases of Salmonella infection and 38 of Campylobacter infection in 2011.

Salmonella infections, which are commonly caused by eating contaminated eggs, poultry and shellfish, appear to have stabilised, from over 100 cases every year in the early 2000s to fewer than 20 cases, now for three consecutive years. This is a remarkable public health success story, as it is now quite certain that this steep reduction has occurred following the campaigns in the mid-2000s to encourage widespread use of Lion-marked eggs sourced from vaccinated chickens.

Similarly, Campylobacter infections, which are caused through poor kitchen hygiene and by

consuming raw milk, undercooked meats and contaminated poultry, have also declined to 38 (2011), far below the recent years’ average of around 48 per annum. Numbers of around 70-80 cases per annum were commonplace in the late 1990s. Again, public health education, leading to better standards of food hygiene, has doubtless played a key role.

Rotavirus infections are responsible for diarrhoeas in very small children. There were 38 cases of rotavirus in 2011, still fewer than the average of 48 per annum. Although they are largely self-limiting illnesses causing no lasting harm, they do cause some distress and dislocation to the family, which has resulted in calls for a vaccination programme. An effective vaccine exists on the market, but is quite expensive.

There were 17 cases of Adenovirus infection in 2011, slightly more than the average of 11, while numbers of Respiratory Synctitial Virus infection fell to only 5 (average: 24). Both these viruses cause respiratory disease in infants and small children.

The rise in Mycoplasma infections, averaging around 80 per annum, appears to be receding, with only 30 cases reported in 2011. Mycoplasma is known to occur in cyclical surges every few years but its exceptionally large surge in recent years has been somewhat of a mystery. However, it generally causes mild unremarkable pneumonia-like infections (although a few individuals may need critical care support).

In 2011, Gibraltar recorded its only death from Swine Influenza (H1N1v) in a 50 year old unvaccinated man, who developed severe respiratory and multi-organ complications of swine flu, but had no other previous illness. At the same time another healthy man of similar age was admitted with severe complications of swine flu, but recovered fully.

A significant infectious disease event during this year was the Norovirus outbreak, resulting in 81

cases of vomiting and diarrhoea, affecting staff as well as patients in four wards of St. Bernard’s Hospital between 31st January 2011 and 15th February 2011. At its peak on 5th February, 17 cases occurred in one day. A clinical diagnosis of Norovirus gastro-enteritis was made, confirmed later by the laboratory.

Although all cases were of short duration and self-limiting, the relatively sudden onset, multiple simultaneous cases and staff sickness created a crisis for the hospital. Strict infection control measures were promptly put into practice with stepwise escalation of isolation zones and attention to environmental cleansing as the disease spread, until control was achieved by mid-February. Cancellation of surgical operations was kept to a minimum. The Authority issued a Press Release advising the public not to make unnecessary visits to the hospital. Norovirus is a highly infectious virus and it is very likely that the disease would have affected many more sick and vulnerable people but for the professional attention of the Nursing, Laboratory and Cleaning staff to infection control procedures and environmental hygiene.

Multi-Resistant Staphylococcus Aureus (MRSA)

MRSA (Multi-Resistant Staphylococcus Aureus) is a variant of the common bacterium staphylococcus aureus that causes boils and pimples. The difference is that MRSA is resistant to common antibiotics (although it can still be overcome with stronger antibiotics).

The MRSA bacterium produces exactly the same disease as its variant – it is no worse or better – but the resistance to common antibiotics makes treatment choices more difficult for doctors. Where infections have to be avoided at all costs, for example, in transplantation, joint replacement surgery, etc., it makes sense to keep MRSA out as much as possible.

The MRSA count fell in 2011 to 19 infections,

Screening programmes help detect cancers at an early stage when they can be treated

Norovirus infections outbreaks can be prevented through strict hygiene and hand washing



significantly lower than the ten-year-average of 25.8. Hospital acquired MRSAs also fell to 12 cases this year. There were two MRSA bacteraemias in 2011, both in very sick persons with intravenous catheters.

It is important to point out that the GHA publishes counts of actual infections, which many jurisdictions do not do – it is common in the UK and elsewhere to publish only counts of bacteraemias, of which the GHA has on average less than 1 per year. These differences should be borne in mind when making comparisons.

ETEC E. Coli

A most significant infectious disease story of Europe-wide significance in the spring of 2011 was that of a widespread outbreak in Germany and elsewhere, of a bloody diarrheal illness accompanied by kidney failure and death, caused by a variant of the commonly occurring bacterium E. coli, labelled Entero Aggregative [Verocytotoxin-producing] Escherichia coli (EAEC-VTEC).

This is an unusual bacterium that is not detected on routine laboratory testing and was probably a mutant species, the mutation conferring upon it a dangerous triad of stickiness, toxin producing capability and antibiotic resistance. By the time the outbreak ended, nearly 3000 persons had been affected, 900 persons had kidney failure and 28 persons had died. Epidemiological investigations subsequently identified the source of the outbreak to be fresh bean sprouts and seed sprouts from a farm in Germany, which had in turn received contaminated unsprouted seeds from Egypt in 2010.

Surveillance was mounted in Gibraltar and the infection control team was put on alert, but no cases were reported. Investigation of the food chain by the Environmental Agency indicated that no sprouts or other food items from the implicated areas were exported to Gibraltar and therefore no public health restrictions were placed on food consumption in Gibraltar.

1.3 IMMUNISATION

Gibraltar has an outstandingly progressive childhood immunisation programme and these vaccinations continue to be carried out every year in accordance with the schedule.

All newborns receive protection against Tuberculosis followed by immunisation against several serious infectious disease threats in childhood. The Human Papilloma Virus (HPV) vaccine given in adolescence protects against cervical cancer and the flu vaccination offers protection against this disease to frail and vulnerable people at all ages of life.

Diseases against which protection is provided free through the public health programme are:• Tuberculosis

• Diphtheria

• Tetanus

• Pertussis

• Polio

• Haemophilus influenzae B

• Pneumococcal disease

• Meningococcal disease

• Mumps

• Measles

• Rubella

• Cervical cancer

• Seasonal Influenza

• Swine Influenza (H1N1v)

1.4 CANCER

Screening

In June 2010, the Government had announced that it would seek evaluations of screening programmes for Lung cancer, Prostate cancer and Colon cancer, following which, the first two were published last year’s report.

In November 2010, the Authority received a report from the Director of Public Health, recommending a population screening programme for colorectal cancer.

Colorectal cancer is Gibraltar’s second most commonly occurring cancer (excluding skin) as well as its third most frequent cause of cancer deaths. Gibraltar’s incidence of colorectal cancer appears to have been lower than in the UK about a decade ago, but its rise has been faster and now stands equal or even slightly higher. 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. It has a high mortality if untreated.

Colorectal cancer is a disease of middle age and later, rising with age and occurring more or less equally between the sexes, although rectal cancer is more common in men. A diet low in fibre and vegetables but high in red meat and animal fat predisposes the development of the disease. About 5–10% of colorectal cancer is hereditary and may develop in younger age groups.

Colorectal cancer is commonly a silent disease and symptoms such as bleeding, obstruction, wasting or pain often manifest too late in its course. However, most grow slowly over 3-12 years and this long latency offers opportunities for timely detection and treatment. If detected before it has spread, people can expect up to 90% 5-year survival after treatment.

There is no single simple non-invasive diagnostic test for colorectal cancer. Hence, the current best screening approach is to use two different methods, one based on a stool study and another on endoscopy, at different times in a person’s life, to detect any early cancers that have developed. Although the tests are simple, the process of delivering a screening programme to the public is complex and more work needs to be done before this becomes a reality.

The incidence of MRSA infections in the GHA continues to fall

Gibraltar’s childhood immunisation programme is comprehensive and top class

Electron micrograph of the Norovirus, cause of winter vomiting and diarrhoeas



1.5 ENVIRONMENTAL PUBLIC HEALTH

Port Fire incident

On the afternoon of 31st May, fire broke out on oil tanks in the port of Gibraltar. Two men suffered burns injuries, of whom, one man who suffered very serious burns (70% of body surface) and was rapidly transferred to the regional burns unit at Seville, where several months later he unfortunately died.

The fire, which burnt for several hours, caused a large and persistent plume of smoke and it was feared that this would have adverse impact on the health of the population, particularly when a change in wind patterns was forecast to occur, which could have the result of stagnating the smoke directly over Gibraltar. The combustion of petroleum products can produce a wide range of toxins. Fortunately however, the fire was put out just before the winds changed, resulting in scattering of the residual plume and consequently the threat to public health passed.

Western Beach

Following the pollution of Western Beach last year, the Public Health department continued to maintain surveillance for pollution related illnesses, but none were reported.

New Hand Sanitizers in St. Bernard’s Hospital

Handwash dispensers had been installed since 2007, within and just outside the wards in St. Bernard’s Hospital. It had been observed for a while that these were found frequently broken, accompanied by spillages and wastage, and the cause was attributed to careless use by the public. However, an audit carried out by the Infection Control Nurses revealed that a design fault was responsible and after further investigation, the existing dispensers were replaced by a modern innovative system.

The new system has electronic sensors that automatically dispense handwash when a hand is presented to it. It is hoped that its “hands-free” design would prevent breakages and that its intuitiveness would particularly help visitors and casual users, encouraging better compliance and more effective hand hygiene. The new system is being introduced throughout the hospital in a phased manner.

1.6 HEALTH PROMOTION

The main Health Promotion event in the early part of the year was the annual No Smoking Day campaign on 9th March 2011. As in the past, this event was jointly organised by the GHA and the MoD. A stall was manned in the foyer of the Infection Control Committee building and leaflets were made available for smokers who wanted to quit.

Campaigns

National Breast Feeding Awareness week was observed during the week on 20th June 2011. The Authority’s midwives hosted a public information stand outside Morrisons’ Supermarket on Thursday 23rd June. In discussing the purpose of their public information campaign, Pat Rice, Sister at St Bernard’s Maternity Unit and a strong advocate for breast feeding, gave 5 reasons why ‘Breast is best’ for both baby and mother:• It allows the mother and baby to form a strong

physical and emotional bond

• It gives the baby all the nutrients he or she needs in the first six months of life

• It protects the baby from obesity, diabetes, asthma, eczema and many infections.

• It is convenient for the mother, always readily available, and best of all, portable!

• It stimulates the womb to contract back to

normal size and helps mothers to regain their figures more quickly.

During the year, the Primary Care Centre, as is now usual, continued to present a series of regularly changing topical health educational displays. The topics included:

Breastfeeding.

Healthy eating (especially nutrition in the elderly)

Diet and Nutrition: Watch your weight; Healthy food choices; Fruit and Veg uptake.

Sun Safety: General sun safety; Care for outdoor workers; Children.

Smoking: Smoking in pregnancy; Never too late to quit; Passive smoking; Teen smoking.

Detecting bowel cancer.

Influenza: Recognising symptoms; Self-care.

Leaflet displays have also covered other health issues such as nutrition in children, physical activity, sexual health, mental health and influenza (including vaccination). In addition, carefully selected posters have also been supplied on request

to the Bayside School PSHE coordinator.

A programme to update the Health Promotion website has begun.

Looking to the future, several new resources are under development. These include a leaflet on Enuresis for parents and a factsheet pack on Stings and Bites for use by Accident and Emergency staff, clinicians and the emergency services.

The following initiatives are also under way:• New resources for the Child Welfare Team are

under development.

• The GOOD Health Award, which has now operated for nearly ten years, is undergoing review.

• A series of TV infomercials encouraging people to stop smoking are in the planning stage.

• The Healthy Eating strategy continues to be developed with the Dietetics department.

Stop Smoking service

The GHA launched its first ever dedicated

The hospital has implemented a modern, hands-free, automatic hand-wash dispensing system to help prevent the spread of infection

The GHA’S Stop Smoking service is a significant development in the battle against cancer

Gibraltar’s first-ever Stop Smoking service



Stop Smoking service in November. This Nurse Practitioner-led service which operates from the Primary Care Centre on two half days each week found its slots filled even before the start date. In accordance with the Government’s instructions, the service refrained from providing the Nicotine Replacement Therapy (NRT) programme.

By the end of the first six weeks, audit showed that 70 clients had started the programme and 44 had remained smoke free at this stage (63%). Only 9 clients had needed NRT and were advised to buy it for themselves.

The Health Promotion officer worked with the Primary Care staff to develop resources to support the new Stop Smoking Service, including Teaching aids, posters, 3 sets of flyers and stationery. A resource booklet to support the client was also developed.

The Health Promotion Officer also wrote TV scripts for a series of TV infomercials to be produced during the following year, covering areas such as passive smoking, smoking during pregnancy, smoking in enclosed places, and quitting smoking.

1.7 PUBLIC ANALYST REPORT

On the 1st of August 2011, a new public analyst was appointed. During the year, he has attended courses on the “Examination and analysis of food” organized by the Association of Public Analysts at the University of Reading and “Drug Analysis” and “Courtroom skills for the Expert Witness” at LGC Forensics (Teddington).

Following this appointment, the modernization of the Public Analyst Services commenced. This required a major capital investment to automate and update methodologies and practices in line with best practice. Users of the Laboratory of the Public Analyst, which include the police, Customs and the Environmental Agency, among others, requested an expansion of the services. Analytical methods were reviewed and updated, and approval was given for the purchase of new equipment,

which will be delivered in early 2012.

The numbers of potable water samples submitted by the Environmental Agency, GHA, AquaGib and the Ministry of Defense for chemical and microbiological quality were very similar to those of 2010. The testing of demineralized water decreased, as no samples were received after September, due to works being carried out at the reverse osmosis plant.

The number of seawater samples received increased by 53% from the previous year. The deterioration in the microbiological quality of seawater from Western Beach, reported in 2010, improved during the summer season of 2011 but then markedly deteriorated at the end of the summer. As a result of this the seawater from Western Beach, which was analysed at three points of the beach and twice a week, continued to be analysed throughout the whole year. This analysis was also carried out on a weekly basis for all other beaches, as pockets of deterioration of the microbiological quality of seawater at other beaches were also identified. Monitoring usually ends in October.

The Environmental Agency collected and submitted fourteen water samples to determine the microbiological quality of the waters from two establishments providing fish pedicures. This practice involves immersing the feet in a tank of water containing Garra rufa fish that nibble off dead and thickened skin. The main public health concern about the use of fish spas relates the potential for the transmission of infection. The results obtained raised matters of concern and following advice on health and safety, infection control and risk assessments by the Environmental Agency, the establishments decided to close voluntarily.

Increased screening for drugs of abuse within the Care Agency and HM Prison Screening resulted in the increased workload for the Public Analyst.

A table of the number of samples submitted to the LPA in 2011 is provided in the Appendix.

The quality of the seawater at Western Beach remained erratic throughout 2011

Palliative Care Team

Diabetes Care Team

2. Chronic Disease Management



2.1 DIABETES SERVICES

OVERVIEW

Diabetes is increasing at an alarming rate, with 336 million suffers worldwide. To put this into perspective, this equates to the whole of the population of the USA. By 2030 the number of people with diabetes is expected to reach 552 million. Prevalence rates vary around the world. The UK incidence is estimated at 6-8% of the population.

In 2011 efforts were made to compile an accurate diabetes register, so that all people with diabetes could receive optimal care. Regular care and timely treatment of problems helps people with diabetes to manage their health effectively and to avoid the serious side effects associated with this disease. The register includes 2158 people with diabetes in Gibraltar at present (700 people were added to the register in 2011), This is around 7.5% of the population.

With an ever expanding case load, staff and patient education are of paramount importance in diabetes management. The goal is to enable people to care for themselves independently where possible, while ensuring that they receive the best possible care they expect and deserve when they approach or rely upon professionals.

The diabetes service is provided by a consultant physician, 2 diabetes specialist nurse, a dietician, an optometrist and other health professionals as needed. The service is divided into a paediatric and an adult service. In 2011, there have been significant developments in the GHA regarding diabetes care.

DEVELOPMENTS

In May, a Paediatric Diabetes Nurse Specialist took up her post, and is responsible for the education and service provision for all children and young people with diabetes in Gibraltar. Her role also includes the provision of services to the adult diabetes population in both the PCC and at St. Bernard’s Hospital.

Developments in the Paediatric Service

Regular nurse led paediatric review clinics were established. All children and young people, and their families, have easy access to the Paediatric Diabetes Service from the time of diagnosis until their transfer to the adult diabetes service at the age of 16. The Paediatric Diabetes Nurse is available through clinics and through direct access via e-mail or phone. The nurse provides advice on all aspects of diabetes to support young people in making informed decisions on the management of their diabetes. Diabetes management plans were established in nurseries, schools, and the college. Transition clinics were established for young people which provide seamless care from the paediatric to the adult diabetes service. This transition programme begins at the age of 14.

Age banded structured education of different age groups was established, which assesses and builds diabetes knowledge in a fun and interactive way.

Information is being collated on the development of an insulin pump service, which is to be introduced in early 2012, offering advanced diabetes management.

Developments in the Adult Service

The Diabetes Specialist Nurse Practitioner continued to provide diabetes care throughout the GHA (Primary Care Centre, KGV and St Bernard’s Hospital), the Care Agency (Mount Alvernia, Jewish Home and Cochrane Ward) and HM Prison.

The adult diabetes service continued to provide an annual diabetes review programme (ADRC) for patients on the PCC diabetes register, which has been in operation since 2004. The Diabetes Specialist Nurses saw an average of 420 people each month. A comprehensive examination is offered that is benchmarked to UK standards (Diabetes UK, 2009).

The ADRC includes measurement or evaluation of:• Height

• Weight

• BMI (body mass index)

• Blood pressure

• Kidney function (blood and urinalysis)

• Erectile dysfunction

• Foot examination (circulation and sensory assessment)

• Psychological wellbeing

• Cholesterol

• HbA1c

• Smoking status

• Medication review

• Insulin update (if appropriate)

This comprehensive review addresses any areas of concern detected, and educates patients about their diabetes management plan. It is also an excellent opportunity to discuss new education initiatives available in Gibraltar, such as the Desmond course.

The Desmond Programme

The Diabetes Specialist Nurse Practitioner, together with a dietician with a special interest in diabetes, received training in the UK and commenced the Desmond Programme for people with diabetes in February 2011. A 6-hour education session is offered on a monthly basis to groups of 6-12 people with diabetes and their spouses.

Access to the course is via self-referral or on recommendation from the GP, nurse or consultant. The course focuses on personal empowerment, by encouraging participants to discuss how the body works, the evolution of diabetes, its management via dietary measures, exercise and medication options.

Local results have proved to be promising with the vast majority of participants achieving a reduction in HbA1c or cholesterol results. Evaluation of the course shows a very high level of satisfaction with the course. One person commented to his doctor that the course had changed his life. Participants were issued with a course handbook to encourage long-term lifestyle changes. In response to a participant’s suggestion, a ‘re-union session’ 3 months after the course was introduces, enabling the group to meet again in order to discuss and build upon the course content. An annual reunion was held at the John Mackintosh Hall to which all participants were invited for a refresher session.

FUTURE

In an effort to stem the tide of diabetes affecting people in Gibraltar, the diabetes specialist nurse practitioner and the dietician also attended training to enable them to deliver a diabetes prevention and awareness programme in 2012. This will help people who are at risk of developing diabetes in the future to delay the onset of Type 2 diabetes or to avoid it completely. A risk evaluation tool will be added to the GHA website, allowing anyone to calculate their risk factors accurately and identify whether they should attend the programme.

The appointment of the paediatric Diabetes Nurse Specialist will significantly improve the care of children and young people with diabetes

The Desmond programme enables adults with diabetes to self-manage their disease, to prevent complications and to lead healthy lives



3. Primary Care Services

3.1 PRIMARY CARE CENTRE

OVERVIEW

The Primary Care Centre (PCC) has an extensive staff complement with a wide-range of duties. A full list of staff roles can be found in the Appendix.

The PCC aims to provide the best possible healthcare to the community, ensuring that services are easily accessible, efficient and responsive to patient needs. High standards of physical and mental health are promoted through a planned programme of health promotion and preventative care. The staff at the PCC strive to maintain a pleasant and safe working environment, with teamwork and good communication being encouraged in order to include all members of the team in decision-making processes.

Developments

Main Reception, GP Sub waiting Areas and Call Centre

The Main Reception offers front-of-house services for users walking into the PCC as from 8.15am. Patients are booked in for the day, advised and/or directed to a particular GP Group if and when required.

In keeping with the strategic objectives of the Department, 2 clerks were successfully introduced in each of the three coloured GP sub-waiting areas. This was a follow-on step from the Re-registration project that commenced in 2010, where patients were registered with a particular GP Group. Each Group worked towards developing their own policies with regards to the following:

• Improved access to doctors

• Better communication with hospital and other services

• Standardisation of treatments

• Improved repeat prescription systems

• Enhanced Nurse Roles

The feedback from service users has been positive, with patients commenting that they have established a rapport with the team of their GP group, and how this has improved their experience of the PCC. Doctors, nurses and clerks have also commented positively on the new setup.

The clerks supervise the counters making all advanced bookings, answering the telephone, recalling patients and rescheduling appointments if necessary. They are also responsible for the pulling and filing of all daily clinic notes and medical documentation.

Following improvements to Customer Services in the Primary Care Centre, there was a shift in trends in the Call Centre, so that clerks operate the telephone lines as from 8.00 am instead of from 8.30am, with five lines instead of two. These are active until 8.45am, after which two lines remain open straight through until 3.00pm. This received positive feedback from users, who now have easier access to the telephone lines at the time of booking appointments. The improvement is evident in the decreasing number of complaints regarding our Appointments Telephone System.

Registration & Entitlement Department

The Gibraltar Health Card/EHIC was first issued in 2005 and renewed in 2010 with a total of 30,960 issued by the end of the year. Cards are periodically issued under all different categories. Statistics are included in the Appendix.

Staff Awards

Ward/Department of the Year: Green Area Nursing and Admin. Reception Team (Primary Care Centre)

This team received an incredible total of 23 nominations, from patients and colleagues, for their loving, patience and caring approach to their patients. The team were consistently praised by

Primary Care nurses provide many services

The improved Appointments Telephone System has received positive feedback from service users



patients for going out of their way to help them, for being respectful and professional and for always being prepared to do extra things to help patients and by their work colleagues for making the organisation and running of the Green Area smooth, fast and effective and using excellent interpersonal skills and good triaging to help prioritise the most needy patients.

FUTURE

The provision of Primary Care to the community is a continuous challenge, and there will always be changes and improvements to be made. Although 2011 has been a productive year, the PCC’s aim for the future is to continue working towards providing better access to care. Specifically, the Advanced Appointments System is currently under review.

3.2 PRIMARY CARE NURSING

OVERVIEW

The Primary Care Nursing Team carries out the following services:

Delivers acute care, chronic disease management, rehabilitation, health promotion and health education to community patients of all ages.

Covers patients at the Primary Care Centre, St. Bernard’s Hospital and the home environment.

Provides ancillary care to residents in the KGV and the Elderly Care Agency.

Works in liaison with the Social Services Agency.

The Services provided include:• Child Welfare Nursing

• District Nursing

• Practice Nursing

• Dental Nursing

• Nurse Practitioner Service

• Cardiac Rehabilitation Service

• Adult Diabetic service

• Dermatology Service

• Mental Welfare Officers

ACTIVITY AND ACHIEVEMENTS

In November 2011, a smoking cessation service was introduced, run by the Nurse Practitioner. The demand for the service was high, and although it has only recently been implemented, it is expected to have a positive impact on smoking cessation and reduction in the community.

The Nurse Practitioner initiated adult and paediatric asthma review clinics at the Primary Care Centre.

The Hypertension Clinic, which advises, educates and manages persons with high blood pressure, was extended from 12 hours a week to 40 hours a week in order to meet demand.

The Nurse Led Hypertension clinic has this year increased their clinic sessions from 3 to 10 per week in order to meet the increasing demand for this service.

Practice Nurses have, as part of their on-going development in lymphoedema care, directed this service to include the use of lymphAssist pneumatic compression for lower and upper limbs. Designed on the same principles of manual drainage the system assists lymph flow in the affected limbs and has proved beneficial in the on-going care of this chronic complaint.

The Baby Swim classes have had the age groups of children extended to include three to four year olds due to popular demand from parents.

There was a notable increase in activity in relation to Child Protection issues with a considerable amount of Health Visitor time spent in liaison with Social Services. The Multidisciplinary Team NSPCC training group, which includes the Health Visitor as one of the trainers, introduced a Tier 2 level of education in their programme delivered to

all essential services.

The introduction of review and management of respiratory and associated allergic conditions.

The introduction of skin prick testing as an allergy diagnostic tool.

The extension of the Spirometry service

The introduction of an extended lymphoedema service to include upper limbs and trunk.

The introduction of a structure Doppler clinic.

The expansion of dermatology services to include assessment and review of treatments in the ongoing management of acne.

There was a considerable increase in the clinical activity of the Cryotherapy service. Up until 2010, cases were treated by the GPs. Since the training and appointment of a Nurse as the Dermatology Nurse Specialist, it has been possible for this service to include all patients presenting with skin lesions. The number of lesions treated with Cryotherapy had a direct impact on the reduction of minor surgical procedures. The introduction of the nurse-led Dermatology hyfercator service for minor skin procedures, carried out during consultant clinics, will also impact on the number of referrals made to the surgical team. The table in the Appendix clearly shows the increase in the number of skin lesions treated by the Dermatology Nurse Specialist.

A Nursing Assistant from the PCC was voted Nursing Assistant/Auxiliary Nurse of the Year at the GHA’s annual Staff Awards ceremony. Lourdes Gareze was given the award for her exceptional commitment to the efficient and helpful management of the patients under the care of the Blue Area doctors and for her calm and considerate manner. Patients specifically praised the support she always provides in helping them to navigate their way through the procedures when additional tests or appointments are required.

The Dermatology Specialist Nurse, Linda Castro, was voted Qualified Nurse of the Year for her consistent excellence in the provision of care for her patients. Linda regularly works beyond and above the requirements of her role. She makes herself available for her patients at any time of the day or night if they have problems with their treatment and rearranges her working times to fit in with the ability of patients to attend her clinic during normal clinic opening times.

TRAINING

Four Primary Care nurse were trained in lymphoedema care, specifically for lower limb procedures.

A Primary Care Staff Nurse received training in Spirometry and skin prick testing.

Continued Professional Development has been ongoing with staff attending courses in:• Breast Feeding

• Immunisation

• Diabetes

• Care of the Dying

• Principles of wound healing and tissue repair

• Assessing of vulnerable adults

• Care of vulnerable children

• Contemporary issues in chronic illness

• NVQ Assessors and candidates training

• Lymphoedema

Nurse-led Hypertension clinics were increased three-fold to meet the increasing demand for this service

The Cryotherapy service enables minor skin problems to be treated in the clinic, thus reducing the need for surgical procedures



3.3 DENTAL SERVICES REPORT

OVERVIEW

The department provides the following services:

• Children’s Dentistry

• Oral surgery - emergencies, maxillofacial surgery and facial lesions

• Braces - fixed and removable

• Care to individuals with special needs

• Dental Care for welfare patients and prisoners

• 24/7 emergency dental cover

Staffing levels in the department were as follows:• Consultant - Orthodontics

• Senior Dental Officer - Speciality-Oral Surgery

• Senior Dental Officer - Speciality-Orthodontics

• Dental Officer - Orthodontics/Paedodontics

• 2 Dental Officers - Paedodontics

• 5 dental nurses

• Clerical officer

General Anaesthetic Dental Equipment

In March 2011, the Dental Department received equipment that allows dental cleaning and fillings to be performed under light general anaesthetic. The equipment was purchased by kind donations from The Gibraltar League of Hospital Friends and the GHA.

The new equipment, along with the regular screening of patients, allows not only fillings but also scaling and cleaning of teeth to help prevent gum problems. Previously, if a patient could not tolerate this dental care in a standard dental clinic, only extractions under general anaesthesia were available. This precluded people with certain medical conditions from having standard dental care.

The dentists, nurses and theatre staff underwent

training and patients have already benefitted from the new equipment.

Children’s Waiting List

Prior to May 2011, there was a significant list of children waiting for initial assessment. Following the recruitment of an additional dentist one day a week, this list was eliminated and all children were scheduled for any follow-up work.

Day at the Dentist – Dental Health Initiative

A new, annual dental health programme commenced in autumn 2011 for all Year 1 school children in Gibraltar. The aim of the programme is to ensure that all entitled school children, of a certain age, have a dental check-up around the time when their adult teeth first emerge.

All 380 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 and provide them with age specific toothbrushes and toothpaste.

This was coordinated with the Department of Education and received good support and feedback from the teachers and headteachers.

Continuing Care

The department continued to screen patients with special needs regularly. A system was put in place so that when a child is placed in care, Social Services liaise with the department, and an appointment can be given. There was an increase in the number of welfare patients seeking treatment and continuation of services to the prison and KGV. The increase in those accessing the department will result in an improvement in dental health in the community.

3.4 GENERAL PRACTITIONERS

OVERVIEW

The GHA General Practitioners (GPs) provide a wide range of clinical services, not only in the Primary Care Centre but also in the Prison, Mount Alvernia, the Jewish Home and Cochrane Ward. They also provide a house-call service for the elderly and the disabled in the community. In addition other services are provided including reports in support of various applications for housing, disability and other medical benefits.

The current complement is 16 full-time GPs with one part time GP. This complement was agreed with Government in 2006 however since then the population served has increased considerably. The relative shortage resulting is a matter that was raised with management in late 2011.

DEVELOPMENTS

Leadership to the GPs is provided by the GP leads who meet monthly with the Medical Director. During 2011 the many issues were discussed in this forum. They included the following:

Nurse Practitioner (NP) Prescribing in which the decision of the Government in 2011 was to allow NP prescribing but only for drugs already prescribed by GPs for certain chronic diseases;

The parameters and performance for the Variable Pay component of GPs income. Some of the parameters included: appropriate ordering of x-rays, registration of palliative care patients, a register of house-bound patients and cost-effective prescribing.

Patient workload particularly as it pertains to population increase, additional capacity in the

The Dermatology Clinic treats many simple skin problems

The ‘Day at the Dentist’ initiative aims to offer all 5-6 year olds a dental check-up while learning about dental hygiene in a friendly environment

Primary Care nurses together provided services to 70,832 patients this year.



Prison and the aging of the population and the possible expansion of elderly care residential homes and palliative care service;

Repeat prescribing programme implementation;

Review of the patient appointment system.

Registration of patients with specific areas at the PCC (Blue, Green & yellow).

FUTURE

In the next year the plans include further developments in the Variable Pay Parameters and close working with Primary Care Management in regard the appointment system and on-going development of a clinical governance system for primary care.

GHA-EHIC Registration Cards must be regularly updated

4. Secondary Care Services

Nurse Prescribing introduced this year enables treatment of longstanding illnesses to be continued by nurses, saving on unnecessary GP appointments.



4.1 DEPARTMENT OF MEDICINE

The Department of Medicine has 4 whole time consultants and 6 NCHDs. Throughout 2011, the medical consultants saw a total of 4,960 patients. The total numbers of patient seen by the visiting consultants was 1,988. The total numbers of procedures carried out was 2,674.

The specialities covered locally are General Medicine, Gastroenterology, Geriatrics, Endocrinology and Respiratory Medicine.

In 2011, the GHA employed the services of the following visiting specialists:• Cardiologist from St Mary’s Hospital London

– 6 monthly• Rheumatologist from Leicester university

Hospitals – 3 monthly• Pulmonologist from Leicester University

Hospitals – 6 monthly• Respiratory Physiologist from Leicester

University Hospitals – 3 monthly• Haematologist from Spain - weekly• Neurologists from Leicester University

Hospital – 2 monthly• Gastroenterologist from Leicester University

Hospitals – 3 monthly• Nephrologist from Hammersmith Hospital

London – 4 monthly• Nephrologist from Cadiz 3 times a week for

dialysis service• Cardiothoracic Surgeon from St Mary’s

Hospital London – 6 monthly

The services offered include:• 24 hour BP monitoring • 24 Cardiac Holter

• Exercise stress test • Lung function testing • Sleep studies • Dialysis service 17 patients• Gastroscopy & colonoscopy • Bronchoscopy • EEG

Bone marrow biopsy

Anti TNF injections

Furthermore, Echocardiography 480 was offered as a new service in 2011.

FUTURE

The Service Goals for the Department in 2012 are as follows:• Replace and modernize the endoscopy unit• Constantly review and revise visiting

consultant programme• Medical pleuroscopy service• 6th NCHD• Associate specialist in Medicine• 5th Consultant • Full time qualified endoscopy nurse

4.2 AMBULANCE SERVICE

OVERVIEW

The Ambulance Service comprises the following:• An Emergency Ambulance Service (EAS)• A Patient Transport Service (PTS) that

provides:• Local Patient Transfers including a

Dialysis Service• Elective diagnosis and treatment treatments

outside Gibraltar• Emergency transfers outside Gibraltar

Emergency Ambulance Service

The EAS has a complement of 22 staff members, who are trained to Emergency Medical Technician standard and provide 24 hour emergency ambulance cover for Gibraltar. The City Fire Brigade provide a supplementary emergency service and are trained to a First Responder standard. The CFB controllers are responsible for the dispatching of Emergency Ambulances in Gibraltar.

The GHA assumed responsibility for Ambulance and A&E cover for the MoD on the 22nd Dec 2010. As at end of December 2011 the emergency ambulance had been called out on a total of 31 times to treat MOD patients.

A summary of the turn-outs carried out by the EAS for the Years 2010 and 2011 can be found in the Appendix.

Patient Transfer Service

The PTS has a complement of 9 staff members, who are trained to Ambulance Attendant standard. It provides a five day week service, and there is a crew on call to cover emergency transfers to Spain after hours and at weekends.

A summary of the Local transfers, and transfers to Spain carried out by the Patient Transport Service for the Years 2010 and 2011 can be found in the Appendix. A summary of the Spanish Ambulances and the St Johns Ambulances used by the Authority for the Years 2010 and 2011 can be found in the Appendix.

TRAINING Paramedic Degree Course

The GHA commissioned an E-learning package with Kingston and St George’s University to develop selected EMT’s to Paramedics over the next 3 years. This is considered more fully in Chapter 8 (School of Health Studies).

Gibraltar has a high quality Emergency Ambulance service

The GHA has made huge investments into the training and accreditation of ambulance personnel, following its take-over of the ambulance service.

New legislation now enables Ambulance Technicians (EMTs) to administer life-saving drugs within their scope of practice



Advanced Life Support (ALS) Instructor

The Ambulance Service Tutor attended the ALS Instructor Course at the Royal Victoria Hospital in Belfast, and is now an official Emergency Resuscitation Council ALS instructor. He is one of 4 ALS instructors in the GHA.

Advanced Life Support(ALS) Programme

There are now a total of 4 ALS qualified staff within the Emergency Ambulance Service.

Acute Life-threatening Events and Recognition Treatment Courses (ALERT)

There are now a total of 11 EAS members of staff that have completed this training. This represents 50% of the total complement.

Intermediate Life Support

Three Emergency Medical Technicians attended and passed the Intermediate Life Support Training Course.

Dignified Control and Restraint Training (DCRT)

The service has a DCRT certified trainer. He is involved in giving DCRT instruction to GHA staff, and 59% (19/32) of ambulance staff have completed the training.

Patient Transport Service – ACA to EMT Training

Ambulance Care Attendants completed the Emergency Medical Technician Course at the end of November. They are now qualified to cover on the EAS when required, and will provide a pool of potential Emergency Medical Technicians when the need arises.

DEVELOPMENTSAdministration of EMT Drugs

Towards the end of the year Parliament passed a law permitting protocol-led prescribing within the ambulance service. With the new legislation, Emergency Medical Technicians, like their counterparts in the UK, are able to administer drugs within their scope of practice.

The drugs which EMTs are now authorised to prescribe include:

• Glucagon 1mg IM

• Adrenaline 300mcg IM (1:1000) via an Epipen

• Aspirin 300mg in tablet form

• GTN 400mcg metered spray

• Salbutamol 5mg / 2.5mg via nebulisation

• Atrovent (Ibatropium Bromide) 250mcg via nebulisation

These drugs, which are safe and simple to administer, are expected to improve clinical outcomes by bringing rapid relief to patients, reducing stress and even saving lives.

Emergency Services Liaison

The task of building and improving on the public profile of the Ambulance Service both within the GHA and to the local population continues. The Ambulance Service participates in monthly meetings with the Royal Gibraltar Police, the City Fire Brigade and Social Service which help to enhance and develop working relationships with these other Essential Services.

New Ambulances

Approval was given in October for the purchase of 3 new front line emergency ambulances. The ambulances were ordered and the expected delivery date is in mid 2012.

FUTURE

Future development will focus on:• The replacement of the Patient Transport

Ambulance Fleet

• Validation for the Paramedic degree programme by the Health Professions Council

• Securing a new location for the ambulance service

• Implementing a Medical Priority Dispatch System

• Develop a succession plan for future leaders of the service

4.3 ACCIDENT AND EMERGENCY

OVERVIEW

The Accident & Emergency Department (A&E) provides ready access to emergency nursing and medical care 24 hours a day. 365 days a year. The department provides clinical services to treat the range of problems with which patients present as an emergency or urgently, from life threatening conditions to minor injury and illness, in all age.

The clinical team in the department 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.

For the past 10 years and especially since the new hospital opened in 2005, increasing numbers of patients have presented to the A&E department; 34,824 attendances in 2011 compared to 24,857 in 2001, with 64% of all hospital admissions coming through the A&E department. For full details on A&E attendances in 2011, see the Appendix.

The service provided can be highly complex and demanding, and for this very reason, a multi-professional group was set up to address issues in this specialist field. The group is composed of both medical and nursing staff with other professionals

and specialists being co-opted depending on the specific topic being addressed. The aim of the group is to provide guidance and ensure that standards of care are continuously improved and provide a service that is based on best practice.

DEVELOPMENTS

Some of the achievements of the past year have included:• Improved communication amongst

professionals and a greater understanding of each others roles.

• Improved communication between Primary and Secondary care.

• Improvements in the quality of patient documentation through the use of audits e.g. Manchester Triage.

• Greater access for staff training e.g. Child Protection, Clinical Audits.

• Fast tracking certain patient groups e.g. children

• Identifying the root causes for waiting times in A&E. This work is ongoing.

• Improved security in the department.

The Gibraltar Port Explosion.

A fuel tank exploded in the Port of Gibraltar at about 3.30p.m on the 31st May. The Royal Caribbean Ship ‘Independence of the Seas’ immediately retracted the gangway and moved a safe distance from the dock. Reports were issued by the Royal Caribbean that 12 passengers had sustained minor injuries and were had been treated on board.

It was reported that two people had been carrying out welding work on the tank were injured in the blast. One of them suffered extensive burns. He was conveyed to Accident & Emergency Department where he was stabilised and prepared from transfer to a specialist Burns Unit. Unfortunately he died as a consequence to the extensive injuries sustained in the explosion. The other casualty did not suffer serious, life threatening injuries.

In 2011, there were 34,824 attendances at the A&E department, averaging more than 1 attendance per resident.

The new Optical Coherence Tomograph will greatly improve the treatment of diseases like glaucoma, diabetes and macular degeneration.



Special mention needs to be given to all the staff of the GHA who were involved or helped in some way in meeting the challenges in managing this incident, and credit should be given to the dedication, professionalism, teamwork and efficiency on display that day.

FUTURE

A&E also provides a sutures and dressings service, which constitutes a significant activity for this department. In the future, it is planned to transfer this service out to the Surgical Outpatients Clinic.

4.4 OPHTHALMOLOGY SERVICES

2011 has been another busy year for the ophthalmic team. The number of patients who attended the Eye Casualty service continued to increase (see the Appendix). 90% of these patients were attended

to, diagnosed, and successfully treated by the ophthalmic nursing staff, and the remainder, being complex cases, were managed by a consultant.

The continuous Cataract Surgery Audit shows a lower rate of surgical complications compared to other European countries. For example, the accepted rate of post-operative Exogenous Endophthalmitis is considered by the European Cataract Study to be around 1%. In the Ophthalmology unit at St Bernard’s, the rate is 0.1% and, according to early audit results, decreasing further. This may be due to the introduction of smaller incisions for cataract surgery which allows for less intraocular exposure to infective agents. The current corneal incision size is a mere 2.2mm, and may further reduce to 1.8mm in the future.

An Optical Coherence Tomograph (OCT) arrived during the first quarter of the year. This advanced equipment is a special laser scanner that can take

extremely detailed images of the retina and has become an essential tool is diagnosing retinal diseases. Although primarily intended for the diagnosis of Macular Degeneration, it is also applicable to Diabetic Maculopathy and can also obtain cross-section images of the anterior segment of the eye. The latter is particularly useful in diagnosing Closed-angle Glaucoma. The OCT is also used for the continuous assessment of optic nerve health in existing glaucoma patients and has quickly become routine in the Glaucoma Screening service. The particular model that was purchased by the GHA is able to display full 3D images. This allows us the rotation and zooming of images in real time, and the viewing the retinal layers from any angle.

All the nursing staff received in-house training on the use of the OCT and are now able to perform a multitude of diagnostic imaging techniques on the spot without the need to schedule patients for future appointments.

Preliminary work has commenced on drawing up clinical competencies for clinical tasks undertaken by the Ophthalmic Nursing Team. Achievement of these competencies will maintain the highest standard of specialist care for patients and will help serve as clinical goals for new staff.

FUTURE

Before the purchase of the Optical Coherence Tomograph, patients with Macular Degeneration were forced to travel to Moorfields Eye Hospital in London to confirm diagnosis and, if applicable, receive treatment. This will no longer be the case and should significantly reduce costs, as patients will no longer need to be sent to the UK for a diagnostic test.

The department is now looking forward to an exciting 2012 with the second Consultant Ophthalmologist and the introduction of new services such as the treatment for Macular Degeneration.

4.5 ORTHOPTIC DEPARTMENT

OVERVIEW

There is one full-time Orthoptist in the department, based within the ophthalmic unit, who works with the Consultant Ophthalmologist, the Ophthalmic Nurses and the Optometrist.

The majority of the caseload is made up of patients under the age of 8 with visual problems such as squints and amblyopia, though adults with double vision and eye coordination problems are also seen regularly. The Orthoptist also provides school vision screening and assessments for people over 70 wishing to renew their driving license. As part of a multi-disciplinary team with the Optometrist and the Ophthalmic Nurses, the Orthoptist also carries our Diabetic Retinopathy Screening and clinics to assess glaucoma. The exact figures for the number of appointments available for the different clinics can be found in the Appendix.

Developments

In September 2011, a newly qualified local Orthoptist joined the department as part of the Government’s Vocational Training Scheme on a full time basis for 6 months. This led to an increase in clinic availability, especially in Orthoptics and Vision Screening as well as providing the opportunity for valuable post-qualification experience to be gained locally.

Future

Discussions between the Orthoptic Department and the local Gibraltar Dyslexia Support Group have continued regarding the setting up of a new Colorimetry service. This is nearing completion, and a plan has been completed for the establishment of a new Colorimetry service. This will be implemented in 2012.

The Eye Department has up to date technology

The Orthoptic service continues to work to improve eyesight in children

The Audiology department looks after 1,200 hearing-aid users in the community



4.6 AUDIOLOGY

OVERVIEW

2011 was a busy year for the Audiology Department. 1,765 appointments were provided. At the end of the year, there were approximately 1,200 hearing aid users in the community. Throughout the year, 90 hearing aids were issued to new users, and 53 hearing aids were reissued. Additionally, there were 54 hearing aid repairs.

DEVELOPMENTS

Waiting list times for new hearing aids rose to 52 weeks at year’s end, and is directly related to the continuing high referral rate from hospital based Consultants. Waiting times for Paediatric referrals or patients requiring hearing assessments were eliminated.

Calibration certificates were obtained for all audiological equipment.

FUTURE

The priorities for the department in 2012 will be:• The reduction in waiting times for hearing

aid issues from 52 weeks to 8 weeks (target date August 2012).

• To address staffing and training issues/needs

• The implementation of the Neonatal Hearing Screening Programme.

4.7 MENTAL HEALTH SERVICES

DEVELOPMENTSDevelopment of the new Mental Health facility

Extensive work was undertaken in 2011 by the Mental Health steering group planning the design and operation of the new Mental Health facility on the site of the old Royal Naval Hospital. The group has representation from clinical staff who will be working in the new facility. Throughout 2011 they have:

• Consulted with patients and staff to identify their vision for the new facility.

• Utilised the mental health strategy to develop operational policies, clearly setting out how the new facility will work in order to ensure that its design and functionality meets the needs of service users.

• Worked extensively with the architects to plan out the detail of the building

• Commissioned a risk assessment to ensure that the design was consistent with modern health and safety and patient safety standards.

• Compiled a dataset of room datasheets, which specify the details of each room.

• Developed a workforce plan for the new facility.

Key Strategic activities in Mental Health services in 2011

An external review was carried out of the Community Mental Health team services in the first quarter of 2011. The findings were presented to the Community Mental Health Team staff, who developed an action plan which include the following:

The Mental Health Team

The proposed new Mental Health facility continued to develop through consultations with patients, staff and experts

The new Mental Health facility under construction

The Mental Health facility is coming up rapidly.



• The update and development of clinical documentation.

• The improvement of the existing facility.

• The reconfiguration of workload with the appointment of two Registered Nurses case managing more highly dependent patients in the community.

• The appointment of a second Sister into the CMHT team.

Approval was obtained for the appointment of a third Clinical Psychologist.

Preliminary meetings were held with South London & Maudsley Hospital with a view to establishing a visiting consultant service and a contract for our Sponsored Patients requiring specialist mental health services in the UK.

Patient Activity 2011

The total number of available beds in KGV was 52. Occupancy has remained high throughout the year. At times the demand for beds exceeded those available, which was managed by the Community Mental Health Team. The average occupied beds per month for 2011 can be found in the Appendix.

During the past year, improved patient management resulted in shorter hospital stays, higher turnover of patients and more care in the community. See Appendix for more statistical information.

Practice DevelopmentIn-house training

As part of the service’s philosophy to deliver care that is individualized for its service users, staff within the Mental Health service continued to maintain their professional development. This was achieved by the development of weekly ½ day in-service training, during which staff received mandatory training in the following areas;

• Moving and Handling of Patients

• Basic life Support

• Infection control

• Fire safety

• Safe and therapeutic observations

• Medication management

• Documentation

• Dignified Care and Responsibility Training

• Safeguarding vulnerable children

• Safeguarding Adults at risk

At present the service has been able to deliver this mandatory training by providing it in-house.

In addition, a 4 day dignity and respect course, developed in-house within the GHA, was delivered with plans to continue this in 2012 as part of the personal development training programme.

Personal Development Training

Over the last year, in consultation with Kingston University, the School of Health Studies and the Practice Development Nurse, a number of staff members took up courses as part of their degrees in nursing. These included:

Mentorship course = 3 staff

NVQ assessors training = 3 staff

Cognitive Behaviour Therapy (CBT) = 6 staff

Documentation

Clear and concise documentation is always high on the agenda for the GHA’s Mental Health Service. All documentation was regularly audited by ward charge nurses and sisters, ensuring that the Nurses, Midwives and Health Visitors Council and the Gibraltar Registration Board guidelines were followed.

Policies and procedures

The development of clear policies and procedures is important. Staff have been directly involved in the research and development of clear nursing policies and procedures. These include:

• One-to-one therapeutic observation of patients

• Therapeutic intervention with patients who are violent and aggressive

• Protocol for the management of patients’ propery on admission.

• Working with patients on a one-to-one basis

• Medication management.

• Smoking policy.

Service user and carer involvement

The experiences and stories of service users and their carers are used by the Mental Health team in order to facilitate service improvements, as the planning of care needs is paramount in the recovery of any mental illness.

FUTURE

The priorities for 2012 are;• To continue the work of the new facility and

prepare for the opening in 2012• To finalise and secure funding for the

workforce plan for the new facility• To prepare proposals and implement a new

grade of mental health worker to meet the needs of the new facility

• To amend and modernise the existing mental

The experiences and stories of mental health services users are used to guide service planning.

Fewer than half the beds in St. Bernard’s Hospital (54/120) are available for admitting patients with acute problems

Bed Management team



health legislation• To establish a contract for services with South

London & Maudsley hospitals for specialist and child mental health services

• To support the CPD programme and ensure that the specialist nursing skills required are available

• To implement the next phase of Practice Development and Clinical Governance in Mental Health

• To deliver the CMHT action plan• To ensure that new sisters and charge

nurses attend a management development programme

Reconfiguration of the wards has improved efficiency and helped reduce infections

4.8 BED MANAGEMENT

OVERVIEW

In 2011, Bed Management proved to be a continuing challenge with a total of 4305 inpatient admissions, of which 2773 of these came via the Accident & Emergency Department. Full details of average occupancy rates can be found in the Appendix.

Stronger links with the Care Agency were advocated generally as a long-term platform on which to further develop a transition of care, from acute inpatient services to community and residential/nursing care outside St Bernard’s and KGV.

Long Stay Patients and Complex Delayed Discharges

Long Stay Patients are patients who no longer have any ongoing medical need, but do require some type of ongoing nursing or rehabilitation support which cannot be met by current external resources (Care Agency, Domiciliary Care, District Nurses or a combination of these) or by relatives or carers.

Complex Delayed Discharges are patients originally admitted as acute cases and whose discharge has been delayed due to numerous factors (housing, social reasons, community support, long-term rehabilitations). Many of these patients become long-stay as transfer out of hospital setting is delayed.

At year end, there wer

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