Health Matters 2014/15 Health Authority Health Matters 2014/15 Gibraltar Health Authority

Foreword by the Minister for Health 5.8 DEVELOPMENTS IN 2014 58 and Environment 5 5.9 BED MANAGEMENT 60

Introduction by Fred Pitto, Chief Executive 7 5.10 CANCER SERVICES 60 5.11 OUTPATIENT SERVICES 62 1. PUBLIC HEALTH 8 5.12 OPERATING SUITE 63 1.1 CENSUS 2012 9 5.13 WARDS AND DEPARTMENTS 65 1.2 VITAL STATISTICS 9 1.3 HEALTH & LIFESTYLE SURVEY 12 6. DIAGNOSTIC SERVICES 68 1.4 CANCER REGISTRY 13 6.1 PATHOLOGY 69 1.5 COLON CANCER SCREENING 6.2 RADIOLOGY SERVICES 70 PROGRAMME 16 1.6 ABDOMINAL AORTIC ANEURYSM SCREENING PROGRAMME 17 7. THERAPY SERVICES 73 1.7 INFECTIOUS DISEASES 18 7.1 PHYSIOTHERAPY SERVICES 74 1.8 HEALTH IMPROVEMENT 22 7.2 OCCUPATIONAL THERAPY 74 1.9 AIRFIELD INCIDENT EXERCISE 2015 30 7.3 NUTRITION AND DIETETICS 76 1.10 IIPHF CONFERENCE 2015 31 7.4 PHARMACY 76

2. PUBLIC ANALYST 32 8. IMPROVING QUALITY OF CARE 78 8.1 LICENSING OF DOCTORS 79 3. DIABETES SERVICES 34 8.2 SAFEGUARDING ADULTS AT RISK 80 8.3 COMPLAINTS HANDLING SCHEME 80 4. PRIMARY CARE SERVICES 37 4.1 PRIMARY CARE ADMINISTRATION 38 9. SCHOOL OF HEALTH STUDIES 83 4.2 DENTAL DEPARTMENT 38 4.3 PRESCRIPTION PRICING AND ADVISORY UNIT (PPAU) 39 10. MANAGEMENT 87 10.1 SPONSORED PATIENTS 88 4.4 MEDICAL SERVICES 41 10.2 HUMAN RESOURCES 89 4.5 PRIMARY CARE NURSING 41 10.3 DEVELOPMENTS 90 4.6 OTHER SERVICES 44 10.4 CORPORATE SERVICES 92 10.5 INFORMATION MANAGEMENT 5. SECONDARY CARE SERVICES 46 AND TECHNOLOGY 97 5.1 AMBULANCE SERVICE 47 10.6 ELECTRONIC PATIENT RECORD 99 5.2 A&E DEPARTMENT 48 10.7 ESTATES AND CLINICAL ENGINEERING 101 5.3 HOSPITAL OPTOMETRY 49 10.8 FINANCE & PROCUREMENT 104 5.4 ORTHOPTIC DEPARTMENT 50 5.5 OPHTHALMOLOGY 52 11. APPENDICES 107 5.6 SPEECH AND LANGUAGE THERAPY 52 5.7 MENTAL HEALTH SERVICES 55 Foreword by the Minister for Health and Environment

As Minister for Health during the time As I leave the Chairmanship of the covered by this report, I am thrilled to Gibraltar Health Authority after five be introducing it to you. years, you will forgive me if I recall with fondness, not just the last five The period covered by the report saw years, but my time over nearly 30 years, tremendous progress in improving as Hospitals and General Manager, Gibraltar’s health service, with and later on the Board. Working in reducing waiting lists, vastly increased Health is a privilege. It brings you into numbers of operations performed, contact with committed professionals, thousands more appointments across dedicated support staff, and a great deal many disciplines, improved access to of humanity. It is special and gives you visiting Consultants, and much more. something special, and is something to At the same time the Unit-centred be cherished. management structure began to show I thank everyone who made my dividends, and increasing involvement journey through the health service – of clinical staff in discussions and at every stage – the experience it has decisions began to bear fruit. been, and with the GHA, its teams Improved on-the-ground facilities and its users, every success in the years also came into operation, notably ahead. the move of mental health from the With great fondness and best wishes archaic ‘KGV’ to the award-winning Ocean Views, and the bringing of our John catering facility from the windswept Dr MBE MP North Mole home to St Bernard’s Minister for Education, Heritage, Environment. itself. Energy and Climate Change

Minister for Health and Chair, GHA 2011-2016 HM

4 5 Introduction by Fred Pitto, Chief Executive

Once again it gives me great pleasure to introduce the New systems have been introduced such as the Gibraltar Health Authority’s (GHA) annual report for Complaints process which is now managed by the the period covering 2014 and 2015. Complaints Handling Scheme which comes under the umbrella of the office of the Ombudsman. The The GHA provides a comprehensive range of health aim of this is to provide a more independent and services for the people of Gibraltar, which includes transparent complaints system. Primary, Secondary, Mental Health and the Ambulance Service, together with tertiary care services provided Achievements have also been made in staff training in either Spain or the UK. and development with the first cohort of Degree nurses graduating, the introduction of a Master’s Whilst most of you may be familiar with our front Degree programme for senior staff, the introduction line services at the Primary Care Centre, the Accident of enrolled nurse training, appraisals for all doctors & Emergency Department or even the Ambulance and the partnership developed with the University of Service, there are numerous departments which may Gibraltar which will see many learning opportunities not be that obvious to the general public, but essential for our staff. in the delivery of healthcare. The annual report provides an opportunity to showcase all services All of this has only been possible through the quality giving the reader a greater understanding and insight of the GHA’s leadership and the dedicated and of most of the departments within the GHA. professional staff that we have.

The report outlines the work carried out by the GHA Although quite a lot of progress has been made during over the years 2014 and 2015, highlighting the success these two years, we all acknowledge that there are still and also the challenges faced. All of us at the GHA are gaps in the service which need to be addressed such committed to provide the best care to our patients as keeping the Primary Care Centre appointment and the quality of the care we aim to provide is our system under continuous review, alleviating the absolute priority. pressure in our Accident & Emergency Department and the pressures placed on our bed capacity by On my appointment as CEO, my initial two priorities elderly patients who do not require an acute hospital were setting up the new Senior Management structure bed to name a few. and the development of the three year strategic plan for the GHA. The strategy sets the direction There is still a huge amount to do, but I am optimistic of healthcare for the next three years, identifies the that we are moving in the right direction. priorities, describes what will be done, individual responsibilities, outcomes and benefits, together with The future will see many new developments such as an opportunity for the GHA to be measured on the new Chemotherapy Unit which will allow the achievements and performance. GHA to repatriate this service and the much needed Dementia Day Facility, but the future will also bring These two aspects have ensured that the GHA has the uncertainty which the GHA needs to plan very right leadership and clinical/corporate governance carefully to address potential difficulties such as the structures in place. Brexit vote and the future of Gibraltar being outside the EU. As you go through the report, one appreciates the numerous accomplishments despite the challenges Finally, I sincerely hope that you enjoy the report and faced. The main achievements have included the in the process gain a greater insight into the GHA, its new Mental Health Facility (Ocean Views), the staff and services. new Catering Facility, reduction of waiting lists and waiting times as a result of the success of Day Surgery I would like to thank all of our staff who work and increased theatre activity. Others have included across the GHA, for the service they provide to our the introduction of a new appointment system at the patients and our community, and the dedication and Primary Care Centre, improved Cancer Services and commitment they have continued to show throughout the implementation of Phase One of the Electronic this period, without them none of the achievements Patient Records Programme. would have been possible.

6 7 1.1 CENSUS 2012 tends to be mobile and some undercounting is also likely. The publication of the report of Census 2012 in mid-June 2015 was a significant event for In terms of age profile, the largest increase public health. This is an important public in the resident population, when comparing event that had occurred regularly every ten the 2012 census to the 1970 census, is in 1. PUBLIC HEALTH years, but had been seriously delayed. Firstly, the group aged 80 and over. This group the date of collection was delayed from 2011 has increased by 1,054 persons, an average by one year, an act that is unprecedented in increase of about 42% per decade. Gibraltar history, other than during the war years. This meant that while every previous In more recent time, the biggest difference Census is counted at ten year intervals, between the 2001 and 2012 Census occurred in persons under 15 years of age, this census has to be counted at an 11 year with females in this category increasing by interval and presumably its successor in 2021 17.7% and males by 13%. This appears to be will be at a 9-year interval. Secondly, the largely due to Gibraltarian births. analysis took 2½ years to carry out it until it eventually arrived in 2015. Households There is clearly a wealth of information The Census also recorded the address of the in it, but a glimpse of it may be had from individual, making it possible to measure the the Population Pyramid in the Appendix, size of the household. The average household which shows striking gender differences and size has shrunk over the decades, in contrast longevity patterns. to the population which is increasing. This suggests a greater supply of housing, as well The 2012 Census of Gibraltar is a record as social trends. of information about the individuals of the Gibraltarian population resident on Census 1.2 VITAL STATISTICS Night, 12th November 2012. Population Persons The Government Statistics Office estimated The total population counted was 32,194, that the resident population on 31st December which is the highest ever on record. It is of 2014 was 33,140. Such estimates are only also the highest percentage increase for each approximate, being based on calculations of census with a 17% population increase since numbers of persons entering and leaving 2001. Gibraltar, but it suggests that the population has been growing at a rate of about 1.5% per Census 2012 is also noteworthy for counting annum. the largest number of to date, 25,444, an increase of 11.2%. However, the Births biggest increase was from 1991 to 2001, There were 439 births in Gibraltar In 2014, when Gibraltarians increased by 14.3%. The and 459 births in 2015, a small but steady Gibraltarian sub-population has constituted around 75% of the population throughout increase over the previous years and this the different censuses taken, although in maintains the trend in recent years. There 2001 it was at its peak with 83%. were two stillbirths in 2014 and one 2015. The Moroccan sub-population has The crude birth rates calculated for the dramatically fallen from 2,798 to 522 a last five years were 15.0% in 2011, 14.7% seemingly precipitous decrease of around in 2012, 13.9% in 2013, 13.2% in 2014 80%. However, this may be an artefact, largely and 13.9% in 2015. After the peak in 2010 due to many in this group acquiring British when it reached 16.4, the crude birth rate citizenship in recent years. This group also may be returning to the normal pattern of earlier decades, during which the birth rates PUBLIC HEALTH 9 of the local population had been lower, the is an increase over previous years. The oldest measure of health in a population. Premature gradually thereafter, with very few men still average crude birth rate for 1998 to 2002 mother in 2014 was 43 years old and in 2015 death is a theoretical concept based on the left alive in the 90s. In contrast, female death being 13.9%. However, as these rates use was 47 years old. assumption that everyone ought to live at rates usually do not rise until the 70s, peak in population estimates as denominators, it is least up to the normal life expectancy for that the late 80s and then fall gradually, with quite important to keep in mind that there could Only 13 babies (3% of all births) were born nation and any death occurring at an age that a few alive over 1000 years. This trend holds be a margin of error in the calculations. in 2014 with birth weights below 2500 is 10% below standard life expectancy might good for 2014 and 2015 as well; however, grams. This slightly increased to 4% in 2015, have been preventable. For the purposes of in 2015 there are two peaks for men, at 70 The absolute number as well as the proportion with 19 babies being born with birth weights this report, all deaths occurring before the and 88, suggesting that men who survive the of births to non-British nationalities has below 2500 grams. The average birth-weight age of 71 were assumed to be premature early-seventies have a very good chance of slightly increased – in 2013, there were 36 remains stable: in 2014, the mean birth deaths. It should be emphasised that this is living for another ten years. All these figures such births (8.2% of all births), whereas in weight of all babies was 3377 grams (7lb only a theoretical concept and that every seem to suggest that while people in both 2015, this increased to 43 (9.4% of all births). 7oz) and 30.1% of all births fell within 5% death under 71 is not necessarily preventable sexes are living longer, where the older years of this parameter; while in 2015, the mean in real life. are concerned, the big gender gap seen in The number of births in the British Forces birth weight was 3364 grams (7lb 6.7oz) and sub-population has fallen dramatically, with the past is becoming eroded, with women 26.8% of all births fell within 5% of this. The proportion of premature deaths in narrowly ahead. 3 (in 2015) and 6 (in 2014), from 15 in each Gibraltar had remained stable in the past, at of the previous two years. These now form All this suggests that the general health status around 20% of all the deaths. However, in Survival after the 90s, longevity seems to be less than 1% of all births, which is much of newborn babies is good. 2014 the number of persons who died before strong in the population. In 2014, there were reduced from around a decade ago, when their 71st birthday rose to 56 (23.3%) and in 50 persons who survived until the nineties the proportion of Forces births used to be Deaths 2015 this rose further to 59 persons (28%). (8 men and 42 women), while in 2015, there around 8% of all births in Gibraltar. The average Life Expectancy in Gibraltar is were 32 persons (6 men and 26 women) in line with the best of European standards. However, it has been remarked upon in The see-sawing of male and female births who did so. Women still substantially outlive several previous reports that there is usually men in this age group. Finally, in 2014, three continues as a curious phenomenon In 2014, there were 240 deaths in the resident a marked and striking gender contrast in persons died centenarians, while in 2015, in Gibraltar. Until 2002, male births population, giving a crude death rate of 7.2, this ‘premature deaths’ group, with only half just one person did. predominated over females every year. From which is similar to that of recent years. In as many women as men. In 2014 too, 16 then on, females have predominated during 2015, there were 208 deaths, giving a crude women and 40 men died before the age of In 2014, the leading cause of death remained even years and males during odd years. This death rate of 6.3. 71, and again in 2015, there were 19 women Respiratory disease with 62 deaths (26% oddity continues for the fourteenth year in and 41 men who died early. of all deaths in 2014. In 2015, Heart disease The mean age at death of males in the a row, with females predominating at 51% was the leading cause with 55 deaths (26% resident population rose in 2014 to 78.9, in 2014 and males predominating at 53% in The number of middle-age deaths, i.e., in of all deaths in 2015). This is the first time in compared with previous years at 76.4 in 2015. the 50-70 age group is another measure of ten years that heart disease has taken the lead. 2012 and 74.3 in 2013. It fell again to 72.7 in comparative premature mortality that has All but one birth in 2015 took place in 2015. As for females, the mean age at death been examined in earlier reports. Again, In 2014, Cancer took second place with St Bernard’s Hospital. also rose, to 83.3 in 2014 but fell to 82.2 in a large gender gap had been noticed in 55 deaths (23%) and Heart Diseases came Teenage pregnancies are used as a measure 2015, compared to the previous years at 82.8 previous years. During the period 2011 to third with 44 deaths (18%), while in 2015 of a nation’s reproductive health in youth. in 2012 and 80.9 in 2013. 2015 (inclusive), 136 men of this age group the positions were reversed with Respiratory died (25.8% of all men who died), when Disease claiming 52 deaths (25.6%) in second Generally, having children at young ages Over the last four years, this averages to compared with only 80 women of this age place and Cancer with 45 deaths (21.7%) in can give rise to unsatisfactory health, 74.3 years for males and 82.4 years for group (13.6% of all women who died). third place. psychological and social consequences for females. Overall, this is a very good standard Furthermore, if only the most recent two both the young mother and her baby. In of longevity for both sexes and shows that years are taken, 2014-2015, the figures are These figures represent quite a contrast to the last four years, the number of teenage people are living longer. Continuing from men (37.7%) and women (12.8%). All this the figures seen at the start of this century. In pregnancies appears to have reduced, 19 previous years, the figures also suggest that suggests that many more men are dying 2000, the positions of the above three causes (2012), 13 (2013), 14 (2014) and 8 (2015), the gap between the sexes is narrowing. which is a welcome trend. younger than women and this gap seems to were widely divergent, with Heart diseases leading the pack (39%) and Respiratory There were no deaths in infants or young be widening. diseases (6%) very low down. The differences The proportion of mothers over the age persons (in 2014). The age of the youngest Finally, the gender differences are also seen have narrowed during the past 15 years and of 35 seems to have settled at around 20% person to die in 2014 was 20, but in 2015, for deaths in the older ages, i.e., over-70s. this is illustrated in a chart in the appendix. throughout the last ten years. The proportion one child died aged 3. of mothers aged 40 and over was constant at It has generally been the case that typically, In recent years, deaths due to Respiratory 4.8% of all births, during the two years with It is common practice to calculate the extent male death rates begin to rise sharply from the late 50s, peak in the late 70s and fall diseases have been increasing steadily at PUBLIC HEALTH 21 births in 2014 and 22 births in 2015. This of “premature deaths” as an arbitrary PUBLIC HEALTH 10 11 about 1-2% per annum and this trend has treated. The GHA now has screening was appointed to provide data capture and It was reported in the previous GHA Report continued in 2014 & 2015. Pneumonia is the programmes in place against these diseases. compilation services for the survey. An that the Gibraltar Cancer Registry had begun most common cause. It should be noted that experienced Information Analyst was also participating in the prestigious international bronchopneumonia is often the terminal Cancer of the pancreas - which is strongly contracted on a consultancy basis to assist in CONCORD research study on global event in very old people and the increase in linked with long term alcohol consumption the more complex data analysis surveillance of cancer survival. In early March respiratory diseases may merely reflect the – was responsible for 5 deaths in 2014 and 2 2014, as part of the process, the Registry longevity of the population. deaths in 2015. The Health and Lifestyle Survey was underwent a strict check of its quality of formally launched on Friday 9th January. its data and responded to suggestions to Although Cancer may have been overtaken Other cancer sites included oesophagus, It aimed to find out the levels of perceived prostate, bladder, etc., in small numbers. improve data quality control. Towards the as the lead cause overall, in persons under the health in the resident population as well as end of March 2014 the CONCORD study age of 70 it remains the dominant cause of Infectious diseases were the cause of 9 gather information on lifestyle parameters required another detailed assessment of the death (38.2% of all deaths in this group in deaths in 2014 and 8 in 2015, slightly less like eating, drinking, physical activity, etc. Registry’s potential scope and future quality, 2014 and 46.7% in 2015). This proportion than that of recent years (13 in 2013 and 15 The Survey would also be able to make with which the Registry has complied. has also steadily increased. in 2012) but there is no doubt that it has comparisons with the earlier Survey and been more prominent in the past few years. examine trends. The participating public In addition, the Registry also uploaded data Five sites, Lung, Breast, Colon, Brain and were reassured of anonymity for the European Cancer Registries network, Pancreas, together accounted for nearly two However, it is likely that these infectious diseases might have been terminal events of namely ENCR Survey and a childhood thirds (60% of all cancers), with 32 deaths The questionnaires from the Health & cancer study questionnaire. in 2014 and 27 in 2015. Unusually in 2015, advancing age as the average age of persons Lifestyle Survey, containing the data collected there were no deaths from Breast cancer. dying from this cause is around 80 years by the door-to-door surveyors, were (83.6 in 2014 and 78.8 in 2015) as against delivered to the department towards the end Lung Cancer remains the number one that of all other diseases, which tends to be of February 2015 and analysis commenced INFORMATION ANALYST cause of cancer death, with 7 deaths in below 80. on the 16th March 2015. The appointment of the Information Analyst 2014 and 16 deaths in 2015. Over one in has enabled research and audit of local public five cancer deaths (23%) is caused by Lung In 2014, Diabetes was listed as a contributory By mid-June, after about a third of the cause in 23 persons (10% of all deaths) health feasible in a way that had never been cancer. Unfortunately, there is currently no analysis had been completed, the unexpected possible before. means of screening for lung cancer. in 2014 and in 20 persons (again 10%) in arrival of the Census 2012 report necessitated 2015. These figures are however unreliable substantial re-writing, as population counts Two examples of the work are shown in this There is no doubt that cancer in general as diabetes is not always recorded on death affect practically every ratio and all the report, on Childhood Obesity and Dental and lung cancer in particular are strongly certificates and could be underestimates. weightings for statistical interpretation. Health. associated outcomes of tobacco smoking. These public health reports have over many 1.3 HEALTH & LIFESTYLE SURVEY At the time of writing, it is likely that the years, consistently campaigned for reforms The previous GHA Report (Health Matters Survey report is expected to be published in to reduce tobacco consumption in the 2012/2013) described in detail the results of summer 2016. ANALYSIS OF CHILDHOOD community. Tobacco is not just the most the first ever Health & Lifestyle Survey of OBESITY significant contributory cause of cancer, but it the Gibraltar people. Following on from this 1.4 CANCER REGISTRY In 1998, Melanie Chipolina, the GHA is directly or indirectly responsible for several success, the Minister in his Budget Speech The restoration of the data quality of the Dietician carried out a survey of the body other diseases. The welcome introduction of 2014 announced the second Health & Cancer Registry database is continuing weights of Gibraltar schoolchildren and the Smoke Free Environment Act (2012) Lifestyle Survey, to take place in 2015. slowly and is likely to take some time. discovered that over a third of the child is helping to reduce the impact of passive Currently, the Analyst is in the processing population was overweight or obese. In smoking and the GHA’s Stop Smoking The Public Health department compiled the of checking that each tumour has been comparison, childhood obesity rates seemed service continues to help smokers to give questionnaire for the survey, which consisted recorded correctly, a process that has to be higher than that of comparable populations. up smoking. But clearly more needs to be of 46 questions, most of which have been done one by one manually, to detect and done to raise the cost of purchasing tobacco externally validated. remove human errors, misprints, missing data It had always been the intention to revisit and reflect the actual cost of the burden on etc., and is therefore time consuming. the question over time, but lack of resources society in the price of the product. The GHA Procurement department carried meant that this was not possible until the out a procurement exercise, resulting in The cleaning of the Cancer Registry is appointment of an Information Analyst in Breast and Colorectal cancers are two the appointment of the local company continuing, although it is a time-consuming 2013. examples of cancers that can be prevented Copywrite plc. to conduct the fieldwork for task and the Information Analyst is by screening. Using simple medical tests, the the survey in accordance with specification gradually building local expertise based on It was intended that the Analyst would disease can be detected when it is silent but provided by the department. In addition, methodology and techniques used by other compare the historic data collected in 1998 still capable of much harm and successfully another local firm, Micro Business Systems countries. with the data currently collected by the PUBLIC HEALTH PUBLIC HEALTH 12 13 school nurses annually, but it transpired that children is an important indicator of the The programme has the following objectives: Figure 2 shows the percentage of children in this was not possible, as the original survey health of the entire community. It is not only Gibraltar aged 5 with Decayed, Missing and pooled children of different ages, while the valuable as a snapshot of the baseline dental 1. To Increase access to the department Filled teeth by School. school nurses monitor only certain years. health status of the child at an early age, but 2. To Provide dental education The Analyst also found that the classification it is also the period at which much of the 3. To Provide tooth brush, tooth paste and Figure 3 the pooled data for Gibraltar in 2011- protocols and centile charts used to define seeds of healthy lifestyles and behaviours are brushing instructions 2014 and the results for children in , , and UK in 2003 as a obese and overweight children in 1998 sown. 4. To Record prevalence of dental disease guide. no longer existed, although this could be and help form further, more targeted dental resolved using special software. “DAY AT THE DENTIST” health promotion CONCLUSIONS PROGRAMME 5. To Welcome the children to a friendly An attempt was made to compare the annually Overall results (DMFT) show that the dental Since 2011, the GHA has run an annual GHA environment collected data to UK figures, but it transpired dental health promotion programme aimed at health of Gibraltar children is similar to that that local nurses collected data at different The Public Health department analysed the of the UK and is steadily improving. young children called “Day at the Dentist”, data collected by the programme during three years. The GHA’s data collection practices devised and led by Dr. Anthony Fearon. were then realigned by policy to measure the consecutive years i.e. 2011-12, 2012-13 and The response to the “Day at the Dentist” children’s parameters at Reception Year and The programme, which is run with 2013-14. The schools included were Loretto health promotion initiative has been very Year 6, as in the UK. the cooperation of the Department of Convent, ’s Meadow, St Bernard’s, good (>88%) and stable throughout the Education, brings all children attending Year St Mary’s, Hebrew School, St Paul’s, Notre three years. However, the proportion of As a result of all this effort, a database is being One at the First Schools in Gibraltar to visit Dame and St Joseph’s First Schools. children who had never visited the dentist gradually built up which should contain the Dental Department in the Primary Care was extremely high in Gibraltar compared to comparable data for analysis in the future. Figure 1 shows the percentage of children in those in the UK. Centre in small groups for a day during Gibraltar aged 5 with Decayed, Missing and which their dental health is measured and Filled teeth by Year. ANALYSIS OF CHILD DENTAL dental education is imparted to them in HEALTH an enjoyable and engaging manner, using Introduction colourful displays, fun quizzes and interactive Measuring the dental health of young materials. PUBLIC HEALTH PUBLIC HEALTH 14 15 1.5 COLON CANCER SCREENING the incidence of colorectal cancer. only be despatched on the 31st of March but for contingency, for example, were the PROGRAMME after that the programme got under way and public uptake to increase to 60%, the service Colorectal cancer (or bowel cancer) is Screening involves inviting persons over the proceeded smoothly. would be unable to cope. New strategies are Gibraltar’s most commonly occurring cancer age of 60 to submit three stool samples using required to meet the programme demand. (excluding skin) as well as its third most specially designed kits that make taking The Public Health department produced a frequent cause of cancer deaths. It is also one the specimens easy and without mess. The range of publicity materials to support the In summary, the Programme has been of the world’s most rapidly rising cancers and samples are tested in the Laboratory for initiative, including a leaflet “Colon Cancer successful in achieving its objectives and has the second most common cause of death the presence of blood and if negative, the – The Facts”, another leaflet explaining the been received well. Uptake by the public is from cancer in Europe and the United States. participant is reassured and the test is repeated Programme, a TV infomercial promoting still short of the mark and resources need every two years thereafter until the age of 74. screening and an instructional video clip that augmenting. Colorectal cancer is commonly a quiet If any time a test is positive, the participant is took the participant step by step in obtaining disease and symptoms often manifest too invited to undergo a colonoscopy, in which and submitting a sample. An audit of participant queries received at late in its course and it therefore has a high the surgeon inspects the inside of the bowel the Screening Office suggested that there mortality if untreated. However, if detected thoroughly to find the cause. In April 2015, at the end of the first year, was still come confusion about how to do the while still confined to the bowel or earlier, an Audit of the Colorectal Cancer Screening test. To address this problem, the department the disease has a good prognosis, with up to After three years in development, the GHA Programme was carried out and the following produced an instructional video on a DVD, 90% surviving after treatment. There is no Colorectal Cancer Screening programme were some of the key findings: which is now inserted into the mailings along single simple test for colorectal cancer, but was formally launched by the Minister with the test-kit since December 2015. 1. In its first year, the Colorectal Cancer organised screening programmes are now on 29th January 2014. However, certain Screening Programme achieved its key Programme activity data are in the Appendix. widely accepted as the best way to reduce teething problems meant that the first batches of the invitations and test kits could Outcome targets of 100% cancer detection, with no false negatives. 1.6 ABDOMINAL AORTIC ANEURYSM SCREENING 2. The Programme picked up both the PROGRAMME two cases of cancer that came within the The Abdominal Aortic Aneurysm Screening screening range. Programme was officially launched on the 3. The current Uptake by the population is 25th February 2015. 41% against the target of 60%, based on UK The aorta, the largest blood vessel in the experience. The reason for this low uptake human body, is under constant pressure as it is not clear, but future improvement is likely. carries blood from the heart. In about 6-9% 4. The Screening Programme had a higher of older men, the wall of the aorta in the than expected level of False Positives (10.6% abdomen can become weak and start to of all tests as against 2% estimated based on expand or bulge, forming what is called an UK figures). The reason for high level of ‘abdominal aortic aneurysm’ (AAA). The False Positive results remains unanswered, condition is rare in women and younger but this is not due to cancer. men. Aneurysms can rupture suddenly as a catastrophic event with less than 20% 5. User experience has generally been surviving. If detected by AAA Screening positive and most problems were quickly and operated at the optimal time, survival is resolved. around 97%.

6. The Programme Target of 3,500 invitations Screening involves a painless, non-invasive per annum or approximately 300 invitations one-off ultrasonographic examination per month is only just achievable with the offered to all men around their 65th birthday. current resources and. It will not need to be repeated unless an aneurysm is found. If an aneurysm is found, 7. The Programme has a resource deficit. it is monitored by the GPs who will also Even at its peak reported performance, it offer advice on slowing the growth of the could meet only 77% of the annual target aneurysm, until surgery is indicated. and forecast demand for 2016, 2018 and thereafter cannot be met with current Prior to the launch date, a lot of preparatory

PUBLIC HEALTH resources. The Programme has no reserve work had to be undertaken. New screening PUBLIC HEALTH 16 17 Campylobacter infections used to average disposal was prepared. A dedicated reception about 60 cases a year in the past, falling to and isolation unit was created within the about 45 per year in the last few years, before Hospital for admitting potential suspect cases starting to rise slightly again (50 cases in 2014 swiftly and safely. The GHA procured stocks and 46 in 2015). Campylobacter infections of the recommended personal protection are spread through undercooked meats, equipment for infection prevention (gowns, contaminated foods and unhygienic contact masks, etc.), together with the policies for with pets. Its decline was accompanied by their usage. strong public health education campaigns of the mid 2000s on improved kitchen hygiene, All doctors in Gibraltar were issued with avoidance of raw milk consumption and the guidance to identify persons who had fever, proper cooking of meats and poultry. More who had visited affected areas or who had recently, there has been publicity regarding been in direct contact with an infected widespread campylobacter contamination person. This response was actually invoked of meat carcasses, which may be why the on three occasions, but other common infections are resurging slightly and more illnesses like malaria and bowel inflammation education may be necessary. turned out to be the causes. The GHA also conducted two separate Ebola outbreak in West Africa exercises to test the Ebola response On 23rd March 2014, the WHO confirmed protocols in November and December an outbreak of Ebola virus disease in south- 2014. The Exercises simulated a patient in eastern Guinea. Ebola is a virus that causes the Emergency department returning from haemorrhagic fever, is spread by simple Liberia and being transferred to the Isolation contact and carries a high mortality. This Unit. The Exercises were successful, with was the first time that an outbreak has been many processes working as planned and with found in this part of Africa and rapidly spread a few learning points as well. software was developed in house with 1.7 INFECTIOUS DISEASES to neighbouring countries, like Liberia and Sierra Leone, soon becoming the largest However, given that the greatest risk to extensive testing and fine tuning. The Laboratory confirmed infections department also produced an eight-sided known outbreak of this disease. European nations arose from the repatriation The average number of Laboratory confirmed of contaminated or infected aid workers, information leaflet in English and Spanish. cases of infection has been around 240 for International travel in the 21st century no In addition, a 35-second infomercial was international protocols were developed for the last ten years. The number dropped in longer makes it possible to ignore distant this eventuality. produced and began to be televised on GBC 2013 to 217 cases, and then fell to 201 in disease outbreaks as unlikely threats. The TV during March. 2014. It rose slightly to 219 cases in 2015. Public Health department commenced A programme of training was instituted Soon after the Abdominal Aortic Aneurysm the task of building up local preparedness for all key staff, with the Infection Control Screening Programme was publically Food-borne infections as a response to the threat posed by the Practitioners offering weekly sessions on the launched, twelve persons who were beyond It is a public health success story that numbers importation of Ebola Virus into Gibraltar. donning and doffing of Personal Protective of cases of food-borne infections continue to suits. Training was also given to officers of the the upper age limit (over 60 years) requested In early August, when the risk became decline over the years. Port, the Environmental Agency, the Police, to take part in this initiative and were tangible in the international context, added to the Programme using the current the Coastguard and the Rescue services. Compared against totals that averaged Gibraltar’s Port protocols were strengthened protocols. around 90 per annum in the early 2000s, with specific surveillance measures applied By September 2015, the threat had passed By the end of the year 2015, a total of 197 the numbers of Salmonella infections have to ships or persons having visited affected and the dedicated facilities were stood down. men had been screened. The programme dropped sharply (only 10 cases in 2014 and 16 areas. The Borders and Coastguard Agency, detected two small aneurysms, two medium in 2015). Salmonella infections dramatically Pier Masters, HM Customs, the Airport and Swine Flu Influenza sized aneurysms and one large aneurysm. A reduced following the campaigns in the the Police were all issued with protocols. The novel H1N1v virus arrived in 2009 and mid-2000s to encourage the use of British was dubbed the “swine flu” virus. Since then, large aneurysm is at high risk and warrants A comprehensive Viral Haemorrhagic Fevers industry standard Lion-marked eggs sourced it has taken over from the regular human early referral to a specialist vascular surgery Policy document covering preparedness, from vaccinated chickens, together with virus and is now the world’s dominant centre, which was promptly arranged by the disease recognition, personal protection, greater public awareness of safe cooking of influenza strain. It generally causes a milder GHA. The other persons with aneurysms infection control, investigation, clinical poultry and shellfish. form of influenza than the human virus, but PUBLIC HEALTH will be kept under close surveillance. management, specialist advice and waste PUBLIC HEALTH 18 19 in a few people, it can cause catastrophic clinically the diagnosis was presumed to be a Martins and Tangier Views as well as to In 2015, the Infection Control Practitioners and even fatal disease. Pregnant women and type of Norwalk virus. As is usually the case, parents of the affected children. The case was carried out audits of the clinical and non- people with certain pre-existing diseases are the outbreak was self-limiting and all those quickly controlled and no further spread was clinical environments in GHA premises for at particular risk. affected recovered without any ill effects. observed. evidence of infectious hazards. The premises included the A&E unit, Dudley Toomey Early in 2014, two serious cases of H1N1v In early August, a small outbreak of Norovirus World Hand Hygiene Day ward, Victoria ward, John ward, Captain influenza A were reported. A young pregnant diarrhoea and vomiting occurred in Mount (5th May 2015) Murchison ward and the Critical Care woman (who had not been vaccinated) Alvernia. All infection control measures Handwashing is a critical skill for the unit. The audits also inspected cannula care and an older woman were both admitted where instigated promptly by the lead nurse prevention of infection and of any onward and catheter care on the wards. The audits simultaneously to the Critical Care Unit and this did not spread to other floors. transmission to patients and others. uncovered areas of bad practice as well as of with acute respiratory distress. Fortunately good practice. both women made a satisfactory recovery and Cluster of Clostridium difficile The World Hand Hygiene Day is an event subsequently, the pregnant woman delivered Clostridium difficile is a bacterium that is promoted by the World Health Organisation. Reports of findings were subsequently sent a healthy baby. Vaccination can prevent swine capable of causing disease, but often lives The Infection Control Practitioner and the to ward and line managers and a presentation flu and the campaign to vaccinate pregnant harmlessly in the intestines of many people, Health Promotion Officer jointly arranged was made to the GHA Executive. women was stepped up once again. because it is kept in check by the normal an event at the Primary Care Centre, flora of the human gut. Sometimes however, alongside similar events all over the world. Other infectious disease matters In late 2015, a case of H1N1v was reported typically after the person has taken a lot of • Two cases were reported in March of in a middle-aged man, whose condition powerful antibiotics which have cleared On the day, Infection Control Nurses tuberculosis, one a local resident and the deteriorated rapidly, necessitating critical the intestines of most other organisms, organised the following events: other a man of no fixed abode. Both were care, but he recovered fully. Family clostridium difficile may become dominant, • spot checks of staff hand hygiene on wards commenced on anti-tuberculosis treatment. (household) contacts were contacted and causing a severe diarrhoea which may be Family contacts were traced where possible offered vaccination. Soon after, a second bloody, resulting in damage to the colon • photos of staff taken with the #SAFE and advised appropriately. case of H1N1v occurred in an older and even death. The bacterium is also HANDS# badge and uploaded to the WHO woman who developed acute respiratory contagious and can spread through contact website. • An unusual cluster of six Pertussis cases distress syndrome. Household contacts were or contamination. occurred in 3 adult couples during October. contacted and offered vaccination, while • Local public awareness campaign on social Cases were unrelated and not known to each some staff contacts and other family contacts In July and August, seven hospital patients media and the GHA website. other. All were treated with antibiotics. also received medical prophylaxis. were found to have Clostridium difficile infection, but at different locations and dates. GHA staff members and the public were • Over the years, Gibraltar has been relatively The annual seasonal flu vaccination campaign Detailed investigation did not point to cross encouraged to participate and test their fortunate not to have encountered too many was started. In the GHA, staff and all long infection as the cause and this was proved handwashing skills at this event, by subjecting of cases of antibiotic resistance. However, in stay patients in both the GHA, Cochrane when samples showed slight differences in their washed hands an ultraviolet scanning 2015, a patient on kidney dialysis was found and Calpe wards were offered vaccination. To bacterial types. Nevertheless, all healthcare device that can detect improperly washed to have infection by a bacterium that was date 392 persons, both patients and staff had workers were advised to increase hand areas. While the results were reassuring in that resistant to the powerful high level antibiotic been vaccinated by the Infection Control washing precautions and use protective the hands of trained professionals consistently Vancomycin. The patient was immediately Practitioners. clothing. Contact precautions and waste bettered that of the untrained public, some isolated and specific precautions were disposal practices were closely monitored. professionals were also chagrined to find introduced to prevent spread of the bacterium. Norovirus outbreaks Doctors were advised by the consultant parts of their hands to be shown to be Relevant departments (Critical Care Unit, In the first week of April 2014, an outbreak microbiologist to use antibiotics prudently. incompletely washed. Proper hand washing Dialysis Unit & the Domestic services) were of vomiting and diarrhoea occurred in techniques were demonstrated as part of staff given advice and deep cleaning of premises Mount Alvernia, affecting all floors and Scabies training. was instituted after the patient left. After 17 residents. Infection control precautions In early 2015, St Martin’s School notified intensive efforts, negative test results were were instigated and floor isolated and one The event was covered by GBC and the reported and it was concluded that the that a child had been diagnosed with Scabies. . This was a successful worker was sent home. Despite immediate The child was reviewed by the dermatology bacterium had been successfully eradicated. measures the outbreak spread to the other campaign and well received by all participants. specialist nurse, who confirmed the diagnosis • In August 2015, six local children who had floors and precautionary measures were and advised that all direct contacts should Environmental audits attended a Scout Jamboree in Japan were applied. Floors were closed for 48 hours to be treated. Approximately 16 people were Infection prevention is an endeavour that put on alert following cases of meningitis visitors whilst the outbreak was at its peak. given simultaneous treatment in line with demands constant vigilance, which the two reported there. However, the event passed All stool specimens collected and tested were good practice guidelines. Education and Infection Control Practitioners undertake. without incident. found to be negative for routine pathogens, information was provided to staff at St PUBLIC HEALTH Clostridium difficile and Norovirus, but PUBLIC HEALTH 20 21 1.8 HEALTH IMPROVEMENT The Health Promotion Officer also joined The Department produced an infomercial use of inhalers prescribed for asthma and This section is currently run by one Health with local Breastfeeding support charities for the GBC on sun safety and broadcast it respiratory conditions. Promotion Officer, Mrs. Daya Dewfall, who at the ’Big Latch On’ events at Casemates on GBC TV from August 2014. has a wide portfolio of duties in the health on 2nd August 2014 and 1st August 2015 to Dental Health Awareness Day 2014 education of the general public, as well as in promote breastfeeding. No Smoking Day 2014/2015 A Dental Health Awareness Day event supporting health care professionals to deliver The Public Health department organised a was held on Thursday 18th September better health. Towards the end of 2015, Sun Awareness campaign event for No Smoking Day on to highlight the importance of adequate a second Health Promotion Officer was The GHA held a Skin Cancer Screening Wednesday 12th March 2014 outside the oral hygiene and dental care. The Health recruited and will be joining the department Day on 26th April 2014. The Health ICC Building on Casemates Square between Promotion Department mounted a display in early 2016 Promotion Officer supported the event by 9:00 AM and 3:30 PM. outside the ICC Building. GHA Dental organising a display for the day in front of the Health staff and Health Promotion staff The Health Promotion department is a busy ICC building, multiple displays within the Staff created a display comprising of an were in attendance. The event was covered one. The following are some of the activities Primary Care Centre and media coverage assortment of posters on the effects of by local media and was well received by the carried out within the department. for the event. smoking on health. Posters were displayed public especially parents of young children. and several leaflets were available for CAMPAIGN EVENTS The Health Promotion Officer and the distribution to the public. An eye-opener for The Public Health department also supported Breastfeeding Dermatology Nurse co-organised a Sun those who have not seen them before and the ‘Day at the Dentist’ campaign, which The Breast feeding Awareness Day took Awareness event for the Brownies (5TH still a favourite for those who have, are the is aimed at small children, by supplying place at Mothercare on 29th May 2014. This Group) at their premises in Varyl Begg Estate. props that include a model of lungs damaged toothbrushes for the campaign. is an important event and the Department The Brownies were grouped into three by smoking and a display unit containing freed up its clerical officer to support the teams and asked to design a poster on sun several jars of chemicals, illustrating just a few Sun Awareness, Sun Safety and Skin Health Promotion Officer on the day. Media safety using cut-outs from magazines, posters of the over 600 chemicals that are present in Cancer coverage was organised for the event and a and colouring pencils/felt tips- the posters tobacco smoke. Sun awareness was promoted at the Gibraltar number of resources prepared. designed were displayed within the Primary Music Festival on 6th September, with Care Centre. Members of the public, including several free sunscreen (provided by the Ministry of school children were given information on Culture) being distributed to all at the event. the ill-effects of smoking and the support available from the GHA to quit smoking. An infomercial was produced and broadcast A GHA Nurse Practitioner carried out to highlight the dangers of sun exposure, Carbon monoxide testing on some smokers featuring Ms Wendy Clouter, who is a to reveal to them the invisible poisons prominent local campaigner in this field already in their system. and a malignant melanoma survivor. The infomercial was relayed on GBC TV during World Blood Donor Day 2014 August and September 2014. World Blood Donor Day was held on 13th June 2014 at Casemates. The event was Noise Induced Hearing Loss organised by the Department and supported Campaign by Blood Bank nurses, the Police, Customs The Health Promotion Officer teamed up and the Fire & Rescue services. The public with staff from the Ministry of Equality & showed keen interest in the event and several Culture and the registered Charity GHITA individuals registered themselves as potential [Gibraltar Hearing Impairment and Tinnitus donors. association] to hold an awareness day for Noise induced hearing loss on 24th World Asthma Day 2014/2015 July 2014. A display was mounted and the A radio talk was arranged on Radio event was covered by GBC and the Gibraltar Gibraltar’s Health File programme for Chronicle. Leaflets and disposable ear plugs World Asthma Day (May 6th), with Nurse were distributed to the public. Practitioner Elizabeth Borges interviewed at the Primary Care Centre. An Asthma awareness event was organised during 2015. This included a workshop on the correct PUBLIC HEALTH PUBLIC HEALTH 22 23 Dementia Awareness Day 2014 World Aids Day 2014/2015 same. Change 4 Life therefore aims to inspire Ocean Views opening The Health Promotion Officer participated The Health Promotion Officer and the a society-wide movement that encourages The new mental health facility ‘Ocean in the Dementia Awareness Day held on Infection Control Team mounted a display everyone to make changes to their diet and Views’ was officially inaugurated at a public Saturday 21st September 2014. Also in in the foyer of the ICC Building on Monday activity levels in an attempt to tackle obesity. event on March 16th 2015. The Public attendance were staff from the Care Agency, 1st December along with the ‘Friends for Life Health department procured promotional Occupational Health and the Dementia and group. Red ribbons were handed out. Several On 9th January 2015, the GHA launched pens with the Ocean Views motif and these Alzheimer’s Support Group. posters and leaflets were displayed. The event the Gibraltar Change 4 Life promotional were handed out at the event. was covered by GBC TV and Gibraltar programme, led by the Public Health World Mental Health Day 2014 Chronicle. A write-up was uploaded to the department, to encourage a new way of ‘The Well Child’ The department organised a ‘Mental Health’ GHA Facebook page. thinking in regard to diet and lifestyle. As A public awareness event titled ‘The Well Awareness campaign on 10th October with part of the launch, four new leaflets were Child’ was held on Friday 17th April 2015 at the support of staff from the GHA mental No Smoking Day 2015 produced by the department for distribution the atrium of the ICC Building to showcase health facility and the Psychological Support The Health Promotion Officer and a within all local schools, titled: the work of the Child Health team of the Group. Nurse Practitioner conducted the annual 1. Ensure your Child has a Healthy Breakfast GHA in promoting the health of Gibraltar’s No Smoking Day (NSD) campaign on youngest citizens and their numerous The Health Promotion Officer set up a Thursday 12th March 2015 outside the ICC 2. Getting the Balance Right accompanying services such as immunisation mental health awareness exhibition at John Building. Several new displays acquired by clinics, school visits, monitoring of growth, Mackintosh Hall from 6th-10th October. the department were mounted for public 3. Fun Snacks for Healthy Kids etc., that contribute to the successful This culminated in World Mental Health viewing. Once again, smokers were given 4. Balancing the Packed Lunch development of young people through Day on Friday 10th October. The event the opportunity to use a Carbon Monoxide infancy, childhood and adolescence. was supported by professionals from the monitor to check the levels of toxic Carbon One thousand copies of each leaflet were mental health team, psychological support Monoxide gas that was coming out of their officially handed over to the Director of This group of GHA staff rarely appears in group and club house Gibraltar. An article breath, even a while after they had smoked, Education at a Press Event on the same day. the limelight, but their work is vital to the on mental health and mental well-being was and once again it proved popular. This is a community. written by the Health Promotion Officer for The department also designed and produced powerful tool that is used regularly in the An array of informative posters was displayed the Gibraltar Chronicle and featured on the smoke cessation clinics – it often shocks, a new infomercial for the Change 4 Life 10th of October. initiative and broadcast this on GBC during and leaflets were tabled, with as many staff but sends a clear message that is difficult to as possible in attendance to meet with the ignore. The event was covered by the media. the month of February. The infomercial World Diabetes Day 2014/2015 alerts parents to the high levels of sugar that public and address their questions. A large World Diabetes Day was held jointly with A new smoking infomercial on passive 4-8 year olds regularly and unknowingly banner-style poster was on view, depicting Diabetes team on 14th November 2014. smoking has been produced by the consume. a collage of the work of the Team, specially A pitch was set up in the foyer of the department and is due to be televised in the designed by local designer Niche Creative ICC Building to raise public awareness next few months. Although the Change 4 Life programme is Solutions for the event. Younger visitors about diabetes and about the education initially and intensively aimed at children, the attending the event received balloons, while programmes offered by the GHA. The Change for Life target audience for the messages it conveys those arriving in prams received bibs with department produced and displayed a banner ‘Change 4 Life’ is a holistic health promotion at the broadest level, is every individual in the GHA Well Child logo. Gibraltar. to promote the new diabetes programme initiative that has been implemented The event was well covered by the media. ‘Walking Away from Type 2 Diabetes’. There nationwide in the UK for a while now. It The Chief Minister Mr Picardo and the Heart Health Awareness Day 2015 were also opportunities for individuals to is led by the UK Department of Health Minister for Health Dr Cortes attended the An awareness event to highlight the calculate their Diabetes risk score and a and brings together professionals from the event. nurse present to educate the public on the health, education and leisure sectors with the importance of heart health was held on importance of prevention in relation to unified aim of improving children’s diets and Friday 13th February 2015 outside the ICC A series of articles describing the work of Diabetes, such as good foot care. levels of activity so as to reduce the threat of Building in conjunction with the Cardiac the Child Health team and the wide range developing preventable chronic diseases such Rehabilitation Nurse. Members of the of services they provide was also published An infomercial was developed with the as diabetes, heart disease, hypertension and Gibraltar Sports & Leisure Authority (GSLA) in the Gibraltar Chronicle in the lead up to Diabetes Specialist Nurse to create awareness others. and of the Physical Activities Association the event. of the disease as well as the GHA services for Mature Older Adults (PAAMOA) also available, such as DESMOND and the Research indicates that people are more attended for a brief period. The event was Sun Awareness ‘Walking away from Diabetes’ programmes. likely to alter their behaviour if they believe well received by the public and was covered The popular annual GHA Skin Cancer that everyone around them is doing the by the local media. Screening event took place on Saturday 25th PUBLIC HEALTH PUBLIC HEALTH 24 25 April 2015 at the Primary Care Centre, in which promotes hand hygiene. Stickers with • The Health Promotion Officer participated healthy products to children, failing which partnership with the Clinical Manager and the Clean Hands logo were also procured for at a conference on Health and Safety in they should be closed. The Public Health staff of the dermatology section. The Health use by GHA staff working within clinical the Workplace at . department has offered alternative resources Promotion Officer helped to organise the settings on the day The presentation included dangers of sun that could potentially be introduced in event and supported it with posters and exposure, skin cancer and ‘the patient’s schools following a pilot study in one school. leaflets, designed and procured for the event. World Diabetes Day 2015 experience’ Members of the GHA Diabetes team and The matter needs urgent resolution. The Health Promotion Officer worked • The HPO supported the annual Citizen’s the GHA Dietetics department joined the ANTIBIOTIC AWARENESS WEEK with the Lifeguards to promote sun safety Health Promotion Officer in a campaign on Advice Bureau event at the Piazza on awareness at the beaches for the forthcoming Friday 13th November held outside the ICC Thursday 3rd December, handing out A high profile campaign was led by the Public summer season. Building. “Brighten your Christmas with Advice” Health department through the European leaflets. The Health Promotion Officer worked with Antibiotic Awareness Week (15th-21st the Department of the Environment and World AIDS Day 2015 November 2015) to promote the awareness SCHOOL TUCK SHOPS Climate Change with the aim of erecting The event was observed on 1st December of antibiotics as a vital life-saving resource, NEED TO CHANGE public message boards depicting the message 2015 with a display outside the ICC Building but also one open to risk of misuse and the that included posters and leaflets on HIV and The Public Health department is leading a long term threat to humanity. ‘Prolonged Exposure to Solar Radiation campaign to tackle the growing problem of The campaign included a number of is harmful BE SUN SMART! - Protect Mental Health Promotion in Schools obesity in children and the gathering risk initiatives with participation from across the Yourself’. Mental Health Promotion in Schools of diabetes in future generations, calling for long overdue reform of school tuck shops. GHA: The Health Promotion Officer set up a Mental Health Week 2015 • On Antibiotic Awareness Day (18th Mental Health Information Stall at Bayside At heart is the problem that School Tuck The Mental Health Week event was held November 2015) a stall was manned outside Comprehensive School on Friday 9th Shops (which are Government supported) from 11th to 15th May 2015 at the John the ICC Building foyer by GHA staff from October 2015. Several leaflets and posters sell unhealthy food items to schoolchildren, Mackintosh Hall. Microbiology, Health Promotion, Pharmacy were displayed and the stand was well including high sugar products like chocolates, and Infection Control displaying posters The department sponsored the printing received by both teachers and students. cakes, biscuits and high calorie drinks. For and information leaflets to raise public of a Poster designed by the young people Other professionals included staff from Club example, a single 380 ml bottle of Lucozade awareness about antibiotic resistance and the with the objective of de-stigmatising and House, Gibraltar, Mental health, Practice contains 10 teaspoonfuls of sugar. Despite importance of correct antibiotic use. Leaflets promoting a better understanding of mental Development (GHA) and Youth services. several appeals and campaigns from health health. The Poster was used as a backdrop professionals and promotional efforts from were distributed to the public and advice suppliers like Gib-Maroc, the School Tuck regarding antibiotic usage given. The event during the event. Other Events Shops are resistant to replacing stock with was covered by GBC TV and radio. • The Health Promotion Officer met with The Health Promotion Officer supported fruits, salads and similar healthy products, professionals from the Care Agency, the • A series of articles by different professionals the week’s events and also a follow-up fund- citing commercial reasons. Ministry of Equality and Mental Health raising event on Saturday 31st May. were published in the Gibraltar Chronicle professionals to discuss a future awareness The Public Health view is that Government throughout the week, covering different event is schools with regard to Eating aspects of antibiotic use, misuse, antimicrobial Crohn’s Disease Day 2015 should not sponsor the marketing of Disorders. resistance, prevention of disease and control The department met with representatives of poor health to schoolchildren, effectively counteracting health education programmes of infection in hospital. a local support group for Crohn’s Disease to • The Health Promotion Officer supported to encourage healthy eating habits in discuss the need for more public awareness the Autism Awareness event organised by • The Gibraltar Chronicle published an children. Furthermore, the school tuck shops on the disease and on inflammatory bowel the Department of Equality at the Piazza on interview with Dr Nick Cortes, Consultant are able to do so from a privileged position, disorders in general. A charity was launched 2nd April 2014. Microbiologist. publicly on 7th May 2015 under the name right on school premises with no direct Crohn’s Colitis Gibraltar in readiness for • The HPO supported an awareness event on competition or incentive to change. Their • The GHA launched comprehensive World Crohn’s Disease Day on 19th May. Stroke organised by John Sheppard and held presence also creates disincentives for parents evidence-based guidelines on antibiotic on Saturday 7th November outside the ICC to send healthy packed lunches and acts as a usage by staff. distraction for children. Hand Hygiene Day - 2015 Building. • A number of retail pharmacies (Morrisons, The department produced a number of • The Health Promotion Officer participated GHA professionals have long campaigned Trafalgar, Wesley and the GHA pharmacy) posters on World Hand Hygiene Day, 5th in the World Alzheimer’s Day event at the that the Government supported school participated in the event as ‘drop off points’ for May 2015 to support the Infection Control Convent on 21st September 2015. tuck shops should switch to supplying the disposal of unused/unwanted antibiotics Nurses in the WHO ‘Saving Lives’ campaign, PUBLIC HEALTH PUBLIC HEALTH 26 27 and other oral medication antibiotics by the to take part in a small quiz on antibiotics • Following a recent incident involving Press public. Collection points were also located at infestation with scabies, the GHA leaflet The following articles were published in the the Primary Care Centre. • 87% knew antibiotics were used for treating on Scabies was redesigned and distributed. Gibraltar Chronicle and local magazines: bacterial infections • A new leaflet for the Meningitis B • A stress-free Christmas • 13% thought antibiotics killed viruses. vaccine was designed and printed. This • Abdominal Aortic Aneurysms is being distributed primarily through the • 10% thought antibiotic resistance was out Maternity and Child Health Departments • Antibiotics of control. • A DVD containing the instructions • Bug-Busting for the Colorectal Cancer Screening programme for distribution to clients was • Change 4 Life Resources Production and Distribution completed in December 2015. • Colon Cancer • A new poster was designed for the • A display of resources on the Colon • Common Winter Illnesses Cancer Screening Programme was laid Colorectal Cancer Screening Programme • Diabetes (series) out for representatives of the Moroccan and displayed at St Bernard’s Hospital (Outpatients and Medical Investigation) Community, who were invited to view and • Drink Safe and be safe this Christmas discuss further resources needs. and the Primary Care Centre . It is planned that the poster also be displayed at other • European Antibiotic Awareness Day. • The Department produced a series of four locations, like senior citizens clubs and the • Flu facts leaflets on Healthy Eating for children Victoria stadium. of school age which were distributed to • Influenza schoolchildren in the new school term in • A leaflet on Intermittent Bowel Disorders September 2014. with approved health content was compiled • Inter-Island Public Health Forum and professionally designed for the Crohn’s conference in • The department procured Leaflets based Disease support group. on the UK ‘Change for Life’ programme • Look after your Heart (7 part series). on healthy eating, aimed at schoolchildren. • Looking after your eyes • The department procured Dental packs Engagement with the Media • New Year, New You. ‘Tooth time’, and distributed these to Radio preschool children. The Health Promotion Officer delivered on • Pregnancy and the Flu Radio Gibraltar’s “Health File” programme • An educational resource DVD for on the following topics: • Safe Hands provide clean care the DESMOND diabetes self-care programme has been procured from the • Shingles • Bug Busting (Head lice removal) UK and is being modified to cater to local • Smoking population. • Smoking in cars • Spring Allergies • The Dental Health department was • Preparing for the Flu • Stopping Smoking supplied with an educational resource, • HIV and AIDS showing the effect of sugar on teeth, for • Summer Health use at the regular teaching sessions. • Heart Health • Sun Safety • Health promotion posters and leaflets • Salt were supplied to St Bernadette’s Resource • Blood Donation • Winter Health (5 part series) Centre. • Spring Allergies • Work of the Child Health department, • Display units were provided to the (4 part series) • Diabetes Maternity department to facilitate display of • World Blood Donor Day health promotional material. • Antibiotic awareness press • Leaflets and posters on the dangers of • World Health Day. smoking were given to the Royal Gibraltar • World No Tobacco Day Police, to address their concerns about • At the event, the public were encouraged smoking in the workforce. • You can control your asthma PUBLIC HEALTH PUBLIC HEALTH 28 29 Infomercials a redesign. Apart from the need to update incident site could be improved. • The Health Promotion Officer presented Infomercials are short video clips produced obsolete information, there is a growing Gibraltar’s experience with Infomercials, at for broadcast on local television and media need for information in the community and A report of the GHA’s experience and which several clips of infomercials currently and containing health educational messages. the demand for more public engagement. lessons learnt from the Exercise has been broadcast on GBC were shown. Being They have proved popular and ideas for new It is currently planned that the redeveloped sent to the Government’s Civil Contingency usually expensive to produce, infomercials infomercials are regularly under discussion website will be ready for launch in late Committee. are not common practice in small territories with the designers. spring of 2016. It will in future operate and several delegates expressed surprise and under a new domain called yourhealth.gi to 1.10 IIPHF CONFERENCE 2015 admiration at Gibraltar’s achievement. Many • An infomercial on Diabetes was produced make it more appealing to younger users. The Director of Public Health led a asked if they could collaborate on future by the department and was relayed from April delegation of four GHA staff to represent ventures. 2015 on GBC television. It aims to show 1.9 AIRFIELD INCIDENT Gibraltar at the Conference of the Inter the range of serious complications that can EXERCISE 2015 Island Public Health Forum, which was held • The Infection Control Nurse described accompany this disease and the importance The GHA participated in an Airfield at Guernsey during 10th to 12th June 2015. an audit of the hospital environment of early detection. Incident exercise organised by the Royal The Forum is a meeting point for public and how the act of drawing attention Gibraltar Police and with all emergency health practitioners of all types who are followed by education can lead to sustained • An infomercial on Colorectal Cancer services participating. These exercises take united by their working in small territories improvements. Screening was broadcast on GBC TV during place every two years, but this Exercise had and has been in existence for over 20 years. June. • The Director of Public Health reviewed two additional objectives in to the usual main Gibraltar hosted the 2000 and 2008 meetings the evolution of the Forum’s website, ending aims – it was intended to test the new Airfield of the Forum. • A new infomercial has been commissioned with the undertaking by Gibraltar to manage on Alzheimer’s disease and Dementia to Incident Plan completed in December 2014 The Gibraltar delegates were the Director the website on behalf of all territories. promote public awareness of this insidious and to test the new Silver Command vehicle of Public Health, one Health Promotion and distressing illness, together with publicity acquired in October 2014. Gibraltar delegates also presented posters on Officer, one Information Analyst and one about the support that families and carers the “Well Child” and “Preparing for Ebola”. The Exercise took place on the afternoon of Infection Control Nurse, all of whom made can get. A new poster and some flyers have 18th March 2015, simulating the crash of a presentations. also been designed. The infomercial is to be The event was covered by local media. commercial airliner, resulting in around 30 The Director of Public Health gave a broadcast in January. • The Information Analyst gave an account casualties. The Exercise Emergency teams press interview to Guernsey Press and also of the findings of Gibraltar’s 2008 Health • A new infomercial is being commissioned from the GHA’s Emergency Department spoke on BBC Radio Guernsey, describing & Lifestyle survey and the lessons arising on Depression. were rapidly deployed to the incident site Gibraltar’s contribution to the work of the from its findings as well as international and took charge of the casualty triaging and Forum. • An infomercial on Antibiotic resistance is clearing procedures. comparisons. under preparation. The GHA Ambulance service successfully carried out operations in evacuating all the casualties, while the St. Bernard’s Hospital Support for Community Education Emergency Department played its part in • The department continues with its core receiving and “managing” the casualties. task of procuring and supplying educational The Exercise also provided the opportunity resources (leaflets, posters, etc.) for GHA use. However, from time to time, it also for GHA senior managers to test their supplied educational materials to some command and control of the incident from private premises such as aon insurance and the “Majax Room” set up in the Board Natwest Bank upon request. Room of St. Bernard’s Hospital. • The Health Promotion Officer met In general, the Exercise went off very well with members of the Police, Care Agency and was widely acknowledged to be a huge and the Crime Prevention unit to discuss improvement over the relatively indifferent alcohol awareness and binge drinking response performance of past years. It appears amongst school children. that there is a greater understanding of how the Plans are meant to work and of individual • The Health Promotion website, which roles. It was however noted that some areas was created in 2003, has been undergoing like activation procedures and facilities at the PUBLIC HEALTH PUBLIC HEALTH 30 31 The Public Analyst is responsible for is partly attributed to the regular analysis providing an extensive range of services of water samples from the water tanks for to the Government of Gibraltar, Gibraltar Commonwealth Park’s pond and fountain Health Authority, Environmental Agency, although Legionella has not been isolated Social Services, from these samples. Samples for general (RGP), (GDP)., microbiology were also received from these 2. PUBLIC ANALYST HM Customs, HM Prison, Ministry of tanks has also been introduced as part of the Defence (UK) and local private companies. surveillance programme. The Food and Drugs Act (1964) (Act. The number of potable water samples No. 1964-07), Part III – Administration, submitted by the Environmental Agency, Enforcement and Legal Proceedings. Section GHA, AquaGib and the Ministry of Defense 32, requires the Public Analyst to perform for chemical and microbiological quality in the statutory function of microbiological and 2014 and 2015 were very similar to those chemical examination and analysis of food and of the previous two years. The milk and drink to ensure the health and safety of the mineral water for samples submitted by public in relation to food standards, consumer the Environmental Agency as part of the protection and environmental matters such as importation programme however increased water samples from our beaches. by 235% from the previous year. Under the Drugs Misuse Act and Crimes Act The number of seawater samples received 2011, the Public Analyst is responsible for by the LPA increased by 101% from the providing a wide range of scientific analysis previous two years. The deterioration in including analysis of drugs of abuse, screening the microbiological quality of seawater for drugs of abuse, toxicology analysis in post from Western Beach continued, slightly mortem cases, as well as providing expert improving during the summer season but witness to the law courts. then markedly deteriorated at the end of the summer and the rest of the year. As a During early 2014 the Thermo Scientific result of this the seawater from Western Gallery was introduced at the Laboratory Beach remained analyzed three times a week of the Public Analyst (LPA) as part of (outside the bathing season) throughout the its programme to automate and update whole year as were weekly samples from the methodologies and practices. This instrument, other beaches (even though EU regulations which is fully automated, is used to determine state no fewer than 4 samples need to be the water quality by biochemical analysis. It taken and analyzed per bathing season). The allows for the simultaneous determination of introduction of the” Environment (Quality a number of chemicals from a single sample of Bathing Water) Regulations 2009” in July and at present can analyse up to eight different 2015 reduced the parameters from 3 to 2 as individual chemicals. In order to increase to the indicators organisms to be detected. the chemical analysis capabilities a manual method using the HACH DR 3900 spectral Screening for drugs of abuse in urine photometer was also introduced to cover an increased by 48%, with both the Care Agency extra nine chemicals not presently available and HM Prison having increased their with the Gallery plus alternative methods to detection programme. The seizure of a large that undertaken by the automated Gallery. number of bales of cannabis resin in several operations by both the Royal Gibraltar During 2014 and 2015 a total of 48 Police and Gibraltar Defence Police required water samples were tested for Legionella the Public Analyst to weigh and analyze pneumophila an increase of 182% from 2012 these to be used as evidence for prosecution and 2013. Both L pneumophila serogroup 1 in court. The number of substances (drugs) and L. pneumophila group 2-15 were isolated for identification which required analyzing in 10 of these samples. L pneumophila is the by the Public Analyst increased by 8.3% most common cause of Legionnaire’s Disease. during this period.

The increase in the Legionella investigations PUBLIC ANALYST 32 33 The Adult Diabetes Service provides care Susan Edwards (mainly at the Primary for people from age 18 years upwards Care Centre) and Julie Parker (mainly at St Bernard’s Hospital). There are daily clinics at St Bernard’s Hospital and clinics Monday, Tuesday, Thursday and 2015 saw the introduction of regular Diabetes Friday at the Primary Care Centre. The continuous professional development 3. DIABETES SERVICES team provides occasional outreach support meetings with multi- disciplinary team to Ocean Views, the Prison and Elderly (MDT) colleagues and GPs in an attempt to Residential Services. improve the services on offer and the skills and knowledge of the MDT members. The clinics cater for people with established and newly diagnosed Type 1 and Type 2 Dr Lorenc, Consultant Endocrinologist also diabetes. People are invited for Annual commenced a weekly dedicated diabetes Reviews to ensure their diabetes is well clinic to review all people with Type 1 managed and the department also see people diabetes annually and more complex clinical with acute problems, for insulin initiation cases of people with Type 2 diabetes. sessions, patient education and psychological support. The team holds weekly review The diabetes service is supported by clinics for women with Gestational diabetes an administrator at the Primary Care and works with midwives and Obstetricians Centre who organises the appointments regularly to support women with diabetes and annual review clinics. It relies on in pregnancy. the professional support of colleagues in the laboratory, dietetics department, The team provides ward visits for hospitalised district nurses and PCC nurses and eye patients and advises on all aspects of department to provide a comprehensive their diabetes care and provide follow up service to people with diabetes. appointments after discharge. An average of 155 people are seen per week in the clinics Developments and on the wards at St Bernard’s Hospital. The diabetes population in Gibraltar has increased by 80% since 2009 largely due In addition to these clinics the team provide to the teams efforts in early identification structured education sessions for people of people with diabetes (earlier screening) with Type 2 diabetes (DESMOND), as well and the development of a Diabetes Register. as sessions for people at risk of developing There are currently 2,575 people on the diabetes to reduce their risk factors (Walking diabetes register. Many of these people do Away from Diabetes). not see the Diabetes Specialist Nurse for The team also provide 1:1 education for the annual review clinic. Regular reviews people with Type 1 diabetes and group allow the opportunity to identify and treat sessions for people with Type 1 in preparation symptoms before they develop complications for Insulin Pump Therapy. of diabetes. It is therefore recommended that all patients with diabetes are offered annual The team supports the School of Health reviews and this is one of the aims of the Studies by providing Diabetes education to team. student nurses, enrolled nurses and qualified nurses and also provides expertise in diabetes The Adult Diabetes Insulin Pump service management to GPs, Consultants and developed further in 2015 with a further 7 Hospital doctors. adults commencing insulin pump therapy. Insulin pump therapy requires a period of Part of their role is to work with the Health education and preparation and commitment Promotion team to deliver several Diabetes from people considering this form of Awareness events each year and contribute treatment. This has brought personal and to articles in local newspapers and magazines clinical benefits for those adults involved about diabetes issues. and has been a useful investment in terms of

resources and time. DIABETES SERVICES The adult diabetes service is provided by 34 35 The insulin pump service will be continued The GHA now has three DESMOND with the plan that an annual ‘pump start’ Diabetes Educators. service can be established to help people to benefit from technological advances in Attendance at UK study events and treatment. conferences gives the opportunity to network and benchmark local services against those The use of continuous glucose monitoring in the UK. The adult diabetes team visited 4. PRIMARY CARE SERVICES has also increased with further investment of Bournemouth, Manchester and London. 4 additional meters to facilitate this. There have been significant developments In 2015 the team devised a diabetes education in the Paediatric Diabetes Service. After programme for Moroccan sub-populations completing an Insulin Pump Degree as there is a high incidence of diabetes in Module with York University, the Paediatric this group and scarce educational resources Diabetes Specialist Nurse has commenced available to them. This will be rolled out in four children on insulin pump therapy in 2016. 2015 that are progressing well. Diabetes Specialist Nurse Julie parker was The GHA Diabetes Strategy is in the process invited to speak about the success of the of being developed. Desmond diabetes programme at conferences in Barcelona (2014) and Birmingham (2015). DIABETES SERVICES 36 37 4.1 PRIMARY CARE Records Department Oral surgery - emergencies, maxillofacial The programme can only continue with the ADMINISTRATION This department is responsible for manning surgery and facial lesions assistance of the Department of Education, This report is intended to provide an the main counter and for the smooth running Department of Public Health, teachers overview of the various administrative of all clinics. The office is composed of 16 Braces - fixed and removable and head teachers. The increase in patient services provided at the Primary Care Centre, clerical officers. Dental Care for welfare patients and number has put more pressure on the service. and to provide an update of the status of prisoners The development of the 5th dental clinic assessment activity undertaken by each unit Registration Department at the Primary Care Centre will address within administration. This department is manned by 4 officers 24/7 emergency dental cover this together with the employment of an whose main responsibility is to register all additional Dental Officer. The aim of the Administrative Service is to eligible persons into the Group Practice support the different sections at the Primary Medical Scheme. This office also interfaces Staff in the department consists of: Oral Surgery Waiting List Initiative Care Centre by: with other Government Departments In Oral Surgery there has been a push to Consultant - Orthodontics Providing a safe and efficient environment including other EU Member states when enhance services, driven mainly by a need to reduce waiting times for operations. This registering / dealing with EU applications. Senior Dental Officer - Speciality-Oral Developing appropriate use of new has been achieved by increasing the number Surgery technologies Administrative Support – Dental of sessions. There has been a dramatic Senior Dental Officer - Speciality- reduction in waiting times, particularly for Providing outstanding service to all Department / Nursing Departments / AHPs Department Orthodontics those patients with acute disease and those customers registered at the Primary Care whose condition can be treated under local Administrative support is provided to all Dental Officer - Orthodontics/ anaesthetic. A reduction in waiting times Assuring well-maintained building and clinical departments. Paedodontics for non-urgent operations under general grounds anaesthetic is likely with the addition of a Quality Improvement 2 Dental Officers - Paedodontics Supporting all members of staff in their whole day’s operating session. Currently, A telephone audit was carried out to ascertain people with oro-facial diseases requiring daily function 5.5 dental nurses the time it took a patient to get through to urgent management are typically seen within our advance appointment telephone line The Administrative Service is comprised of 9 Clerical Officer two weeks of referral and treated within four sections with 40 Employees. A brief summary service. Based on these results, the PCC has weeks. This compares well and conforms to of the responsibilities of the nine departments successfully managed to reduce waiting times guidelines that have been set by the National from 20 minutes to 15 minutes during peak Day at the Dentist – Dental Health included within the administrative service Health Service in the . hours. This has been achieved by allocating Initiative are presented below: th two extra staff members to the 5 already in The 4 annual visits of the year 1 school Preventative Dental Care place. children to the department continues to Unit General Manager & Primary be a success. The aim of this programme The department continues to monitor Care Manager The Primary Care Centre received numerous is to ensure that all entitled school children the dental health of Dr Giraldi Home, St This office is responsible for the overall complaints about the advance appointment have a dental check-up around the time Bernadettes Centre and St Martin’s School. supervision and coordination of various telephone line service, as after playing when their adult teeth first emerge. All 452 The department is also in regular contact administrative departments within the the message, it disconnected the caller Year 1 children were invited to attend the with Social Services to ensure “children in Primary Care Centre. It interfaces with automatically. This caused the person to call department with their classmates and had care” have access to the service. other Government Departments including on various occasions. However, together the dentist check their teeth, show them with the IT Department, the Primary Care the Pension Department and Department how to brush their teeth properly and 4.3 PRESCRIPTION PRICING AND Centre was able to successfully upgrade the of Health in UK. It also deals with all generally introduce them to the dentist in a ADVISORY UNIT (PPAU) telephone system which now allows the environmental and safety training as well as welcoming and friendly environment. The The Prescription Pricing and Advisory Unit caller to remain on hold in a queue system. compliance with Government and GHA visit also provided the opportunity to give have been entrusted with various supportive Policies. the children further appointments depending roles within primary care, since its inception 4.2 DENTAL DEPARTMENT on their dental needs, removing the reliance in 1999. Although it is staffed by only a Primary Care Administrator Overview of parents to initiate contact with the dentist. handful of hardworking and knowledgeable staff, its remit is very extensive. Its roles This office oversees the Records Department The department provides the following include both back office administrative tasks, and coordination of the administrative staff. services: The statistics collected by the department It is also responsible for the smooth running show that, not only are increasing numbers as well as patient facing services. of clinics, on call duties and community Children’s Dentistry seeking to use the service, but that the dental sessions. health of Gibraltar children is similar to that Administrative Roles Dental care to individuals with special needs of the UK and is steadily improving. Its primary function has historically been to PRIMARY CARE SERVICES CARE PRIMARY SERVICES CARE PRIMARY 38 39 Part of its role is also to assist patients in of life through managing pain and other sourcing their medication by helping them distressing symptoms associated with a find a pharmacy which stocks a particular serious illness in their home or at the Cancer item, if it is in short supply or difficult to find. Relief Centre. If none is available the PPAU liaises with the prescriber and pharmacies to try and obtain 4.5 PRIMARY CARE NURSING an available alternative, thus ensuring, as far The Primary Care Nursing Team has as is possible, that the patient does not go continued to improve and develop its without. services in their commitment to deliver the We also help formulate and run different highest standard of care to patients on site initiatives to improve patient care within the and in their home environment. Nursing primary care pharmaceutical provision remit staff have been closely involved with the and serve as a valuable information resource electronic health record programme which for healthcare professionals and patients alike. was launched in June 2015. Primary Care The PPAU supplies information concerning services formed part of the first phase and medication availability, licensing and Nursing staff have quickly and efficiently contraindications, and dosing to assist with adapted to the changes required for their prescribing and patient safety and to offer current working practices. assistance with signposting where required. Nurse Practitioners Repeat Prescription Post box Nurse Practitioner Elizabeth Borges, as A post box with the relevant application form a member of the British Primary Care has been set up in the PCC’s main waiting Respiratory Society, has taken the lead in area to facilitate patients obtaining a “Last respiratory care, introducing best practice Prescription Appointment” only. It is used guidelines and innovation in respiratory when the patient’s last prescription is due to care. She has been liaising with GPs, A&E be dispensed or has been dispensed, but not and Nursing, introducing first point of care act as administrator to the GPMS (Prescription a medication shortfall, while awaiting a GP before, this is an alternative to requesting a guidelines for asthma and other chronic Scheme) and liaison between the GHA and appointment. The PPAU liaises with patients Last Prescription Appointment in person. respiratory conditions, and scheduling of community pharmacy contractors. Within GPs, pharmacists and other healthcare follow up quick access appointments to her this role, the PPAU annually processes professionals, to verify need for medication This service has also been extremely useful for clinics. almost 250,000 prescription forms dispensed and organise the issuing of prescriptions. The the staff as it enables them to administer the by local pharmacies and whilst doing so PPAU also runs and administers the GHA booking of appointments, decongesting the District Nursing attempts to improve prescribing practices endorsed emergency supply system, which appointment requests received at the counter The district nurses have undergone and patient safety. In addition, all handwritten authorises pharmacies to issue a limited and requests made via the telephones. significant training and update this last year, prescriptions are processed and electronically amount of chronic medication to Primary having participated in the internal training entered once they are submitted to the Care Centre patients who have genuinely run The PPAU is always striving to improve modules provided such as palliative care, department, ensuring all GHA prescription out of medication and have an appointment its services, increase its efficiency and assist infection control and dementia care. All information is readily and promptly available booked. This further extends the unit’s ability patients in having the best possible healthcare candidates successfully completed to a very to the prescriber, on the patient’s electronic to help meet genuine, chronic medication experience within its remit and beyond. good standard. medication records. needs, reinforcing the PPAU’s role as a vital resource for patients unable to see their GP 4.4 MEDICAL SERVICES Child Health Part of the GPMS administrative role and running out of their regular essential From 2014 to 2015, the Primary Care Child Health Services operates from the includes providing monthly updates to the medication. Centre has seen a significant increase in the Primary Care Centre providing specialist Gibraltar Drug tariff, as well as periodic number of General Practitioners. The GHA skills in the monitoring and assessment updates to the Gibraltar National Formulary The PPAU also assist patients and has recruited 3.5 more doctors to undertake of child development, family support and to try and encompass new initiatives and healthcare professionals with medication General Practice bringing its numbers up child protection. The team comprises of assist in healthcare provision in general. and prescription queries originating from to 20. two health visitors and five senior registered secondary or tertiary care contractors. It nurses offering services from birth to 18 Patient/Healthcare Professional helps transpose and translate Clinica Radon The department has also seen the years of age. These include primary home Facing Roles and Xanit prescriptions and discharge letters, appointment of a Part-time Palliative Care visits, hearing testing, well baby clinics, The PPAU offers patients assistance with to aid local prescribers and pharmacies in GP to focus on improving a patient’s quality specialist paediatric clinics, enuresis clinics, PRIMARY CARE SERVICES CARE PRIMARY obtaining chronic medication in the event of issuing the GHA reimbursable equivalent, to SERVICES CARE PRIMARY 40 help provide seamless care. 41 School Years 12 and 13 were included in There were over 307 attendances on the day a catch up programme. This vaccine was and feedback from the public was extremely replaced by the Meningitis ACWY which positive. included the C component and additional strains. This was again followed by a catch up Practice Nurses programme for school years 13. 2015 also saw The lymphoedema nursing clinic received the introduction of the Meningitis B vaccine a second place award at the British Journal for all babies born as of September 2015. of Nursing annual ceremony. The journal recognised the team’s work in developing The department will look to further develop a totally nurse led service in response to the the hearing programme to include pre- needs of the community and providing the school children in order to identify children latest techniques and practice in the field. with acquired deafness. Cardiac Rehabilitation Service Dermatology Service Cardiac Rehabilitation is another service Additional developments are the introduction which received a third place award at the of the skin cancer screening day, and open British Journal of Nursing Awards. The access day where members of the public with Innovation award acknowledges the work concerns about skin lesions were invited to of nurses who had started a service and attend without previous appointments and be maintained and developed it. 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.

assessment of developmental milestones, and delays due to the hearing impairment. The the management and administration of the initial test AOAE (Automated Otoacoustic childhood immunisation programme. Emissions) has since its implementation in April been successfully carried out on 445 In addition they run a School Health children. programme which provides pre-school entry assessments, monitoring and health education In July of 2015 staff undertook further training sessions to First and Middle school children to introduce the second stage assessment and a drop in service for senior schools. The AABR (Auditory Brain Stem Response) staff also hold annual information sessions which is carried out following a failed AOAE for school teachers. assessment and determines whether the baby requires referral to a specialist centre. A total The Child Health department works closely of 24 babies have undergone this test since with the Social Services department in its implementation, with only one referral relation to the Safeguarding of children. This required for specialist attention. represents a very significant portion of the Health Visitor workload. The overall benefits of this initiative for the children are significant in relation to their In 2015 the department introduced the new- normal development in the achievement of born hearing screening programme which milestones. For the families the introduction replaced the 8 month distraction test. This of the AABR has resulted in the removal procedure allows the identification of hearing of what constituted considerable stress and loss within 10 days of birth, enabling the disruption. formulation of a treatment plan which will ensure that a baby identified with hearing loss In 2014 the Meningitis C vaccine was added will not suffer consequential development to the childhood immunisation programme. PRIMARY CARE SERVICES CARE PRIMARY SERVICES CARE PRIMARY 42 43 4.6 OTHER SERVICES Big Hand System British Sign Language - Video Link The Primary Care Centre introduced the Electronic Health Record The implementation of digital dictation British Sign Language Video Link Service On the 24th June 2015, the Primary Care technology to the Primary Care Centre for patients with hearing impairment. Centre introduced EMIS Web (Egton has proved an economical and practical British Sign Language is a visual form of Medical Information System), patient’s process which can be utilised across the communication using hands, facial expression electronic record. GHA resulting in an improved service to patients through quicker turn-around and body language useful for people with This system will help transform the provision time of correspondence from clinician, hearing impairment. of frontline care, ensuring better outcomes to secretaries to patient. The electronic British Sign Language interpreters allow for patients and increased efficiencies not workflow supports mobile and flexible communication to take place between people only within the Primary Care Centre but working arrangements therefore helping to who have a hearing impairment and clinicians. throughout the Gibraltar Health Authority. alleviate the management of workload across the organisation, plus developing a cross- The electronic healthcare system will This facility has been installed in the Dental over support for secretaries during holidays provide healthcare staff with instant access Department, and the three GP clinics. to accurate patient information and effective and unplanned absence in turn improving tools to communicate, or refer patients, across staff satisfaction. During 2014, a text mobile phone service was multiple healthcare settings and enhance also introduced to assist people with hearing support for care in the community. impairment to make advance appointment bookings over the telephone. PRIMARY CARE SERVICES CARE PRIMARY SERVICES CARE PRIMARY 44 45 5.1 AMBULANCE SERVICE The introduction of a Paramedic Clinical This department is divided into two sections; Governance framework ensures patient best The Emergency Ambulance Service and care and quality assurance of paramedic Patient Transport Service. The latter is staffed practice. The EMTs’ and ACAs’ performance by 9 Ambulance Care Attendants (ACA) and and clinical skills are also monitored by an is responsible for cross-border inter-hospital appointed ambulance clinical development 5. SECONDARY CARE SERVICES transfers, local transport of dialysis patients, and training officer. transfers of patients to and from other local agencies and supporting the emergency The Ambulance Service continues to work service as drivers, when this service has very closely with other emergency services manning shortages. The emergency service, and agencies. As a result the service has together with the Gibraltar Fire and Rescue trained the Royal Gibraltar Police maritime Service ambulance, covers all medical/ section and trauma emergencies in our community. mariners in the management of casualties at Its complement includes 18 Emergency sea. Major incident response and training has Medical Technicians (EMT) and 4 registered been reviewed and more effective methods Paramedics. Other staff include one Patient are now in place. Transport Service dispatcher, one Station Officer and the Chief Ambulance Officer. Future It is planned for the transfer of the Gibraltar Developments Fire and Rescue Service ambulance over The introduction of the Paramedic Response to the GHA ambulance service and will Vehicle has had a significant positive effective provide an integrated pre-hospital service to on pre-hospital care with Paramedics being the community. able to support fellow EMTs with advanced Plan to train the existing four paramedics to skills at a moment’s notice and assist GFRS practitioner level with the aim of improving controllers in triaging calls. SECONDARY CARE SERVICES CARE SECONDARY 46 47 patient care and supporting community 2. Ward clerk cover. problems. The project was overseen and of two full time Hospital Optometrists clinicians. Since March 2015 the A&E department has supported by GHA Project Managers. who are responsible for the delivery of the six ward clerks who work a 24/7 Rota to following eye care services. cover the reception area. On June 24th 2015 the department went 5.2 A&E DEPARTMENT live with the new EPR program. The Children’s Service The Department provides access to emergency implementation process was seamless and a • Advantages include: Children who are found to require vision nursing and medical care 24 hours a day, 365 great success. Benefits include; correction following vision screening by the days a year to over 33,000 potential patients. • The Waiting room is now overseen by a Orthoptist as at age 4-5yrs, are tested and The team provide clinical services to treat a member of GHA staff virtually all the time. • The Electronic Manchester Triage Tool wide range of problems with which patients reviewed regularly until age 8. Over 8 year require either emergency or urgent care • Timely reception of new attenders • Patient history as well as scanned olds are discharged when the visual system without prior appointment, either by their documents and investigations are has finished developing and there is no own means or by ambulance. The clinical • Registration of non-entitled patients immediately available longer a risk of developing a lazy eye. Exempt team seeks to provide patients with the best without time consuming administrative patients and those with special needs are kept • Workflow monitors highlight progress of clinical care as quickly as possible, as well as procedures under review beyond this age. A service is interventions and help in assisting triaging to allay the distress and anxiety that is often also provided for children in Care. • A friendly face for patients waiting to be associated with accidents and emergencies. seen, in the previously isolated waiting area • Appointments for the dressing clinic can be booked electronically. Adult Refraction Service In June 2015 the GHA went Live with • The retrieval of patient notes is now done This service provides refraction and disease the new Electronic Health Information quickly by the ward clerk without the need • A variety of audits can be undertaken detection/management to the following: System and A&E, together with the Primary of calling in Records Staff such as attendance numbers, incidence of Hospital in-patients, residents of Ocean Care Centre were the first departments to illnesses, admission patterns and waiting Views, Elderly Care Agency, Jewish Home, implement this. All patient details and data • Administrative work is now done as times Dr Giraldi Home, Her Majesty’s Prison collected during a patient’s episode of care needed Service and those in receipt of social within A&E is now stored in the system. 5. Remote Monitors assistance benefit. Additionally the dept. provides refraction for Ophthalmic Unit In 2015 a section of staff successfully 3. Medical Staff All of the patient cubicles in the “Majors” patients who have an eye condition affecting completed the BIPAP Non-Invasive The recruitment of extra A&E clerks has area of the Department have been fitted their vision and/or who have undergone eye ventilation training session. An on-going improved the cover for the department with observation monitors that display vital surgery, the most common being cataract programme has been developed for A&E throughout all shifts. observations. extraction. staff to improve staff’s knowledge and skills The new Rota incorporates internal cover in assisting the Intensivists with intubation in All information is displayed and stored making the department independent of the the department with the aim of improving on a central monitoring system allowing Outpatient Service need to use locum doctors. the management of the critically ill patient. observation, analysis and quick response to The aim of this service is to exclude and any clinical information. diagnose common eye conditions in referred An Associate Specialist has been appointed. The last two years have seen the largest and patients such as cataracts, retinal problems The main role is to coordinate Rotas, 6. A Road-map for the future and glaucoma. most tangible improvements in the A&E organise departmental teachings and The re-development of the A&E Department in a long time. represent A&E at the Medical Executive as Department which will include an well as other managerial and strategic roles. Medical Contact lens Service 1. The refurbishment and re-design of the extended waiting and clinical area are at an This service was introduced in 2013 for Waiting Room is complete. advanced planning stage patients who are unable to obtain appropriate 4. Symphony, the Emergency levels of vision with spectacles, due to • A new patient reception area has been Department Information System The strategic plan for the coming year conditions affecting the cornea e.g. corneal developed. The A&E was the first department in the includes the expansion of “Point-of-care” scars, grafts and degenerative disorders of the Hospital to introduce the Electronic Patient testing devices for several blood tests giving • A window with call button connects the cornea such as keratoconus. These patients Program (EPR). The journey from planning results within a few minutes. The benefits of waiting area with the new Ward Clerk are fitted with contact lenses with the aim to implementation has been a great this will be a quicker response to abnormal Office, which now forms an integral part of of achieving a level of vision which is not learning experience for all staff and serve results and shorter lengths of stay for the Department and improves security for achievable with spectacles. Complex cases as a blueprint to roll out the EPR program patients. staff. or patients with disease progression are throughout the GHA. referred to Moorfields Eye Hospital in UK • A TV screen in the waiting area streams 5.3 HOSPITAL OPTOMETRY Training of over 50 staff was accomplished for treatment. information about A&E procedures and The Hospital Optometry Department is through a “train-the-trainers” programme. GHA Services keeping the public attending based within the Ophthalmic Unit of St Experienced users share their knowledge A&E informed. Bernard’s Hospital. The department consists

SECONDARY CARE SERVICES CARE SECONDARY with others and assist with queries and SERVICES CARE SECONDARY 48 49 Diabetic Retinopathy Screening and on wheelchairs, patients with cognitive conditions e.g. multiple sclerosis Irish Orthoptic Society visited and awarded Co-Management difficulties and children. the Department accreditation to receive This provides screening for the ocular • Treating eye coordination deficits in students. From 2014 – 2015, the Department children and adults using Orthoptic complications of diabetes primarily affecting Future supervised a number of students at various exercises the retina known as Diabetic Retinopathy The Optometry Department continues stages during their degree, teaching them valuable core skills and assessing them (DR). Those diagnosed with DR are either to face the challenge of an increasing • Ensuring speedy rehabilitation of patients against the University curriculum, with the monitored or referred to the consultant for population with Diabetes requiring Diabetic who have suffered stroke and acquired brain assessments counting as part of their degree. treatment depending on the risk to sight. Retinopathy Screening, whilst alongside injuries and have vision problems The department works closely with the adult delivering its core Optometry services. The The Department is proud to be contributing diabetes nurse specialists. ultimate aim of a screening program, is to • Monitoring glaucoma and diabetes as part towards the future Orthoptic workforce and target as near to 100% of the screening of a multidisciplinary team - long term eye raising the profile of St. Bernard’s Hospital as Glaucoma and Ocular Hypertension population as possible. In order to do so, conditions a teaching hospital. Screening and Co-Management a change in service delivery model and In 2015 the Colorimetry Service was This provides further investigation techniques additional resources are required to be able Orthoptists are ideally placed to ensure effective introduced, in collaboration with the local to enable a diagnosis of glaucoma or ocular to meet the demand. services for patients. They work closely with Gibraltar Dyslexia Support Group. This is in hypertension for high risk groups referred Ophthalmologists and Optometrists within essence an extension of the already existing to by opticians or GPs. Ocular hypertension Space continues to be an issue for the the Ophthalmic Unit in a multidisciplinary coloured overlay assessment and results in cases are monitored for progression to whole Ophthalmic Unit as we are currently team to treat and formulate management the prescribing of Precision Tinted Lenses to glaucoma. The optometrists also monitor working to full capacity. It is hoped that plans for diseases such as diabetes, glaucoma help reduce Visual Stress and make reading patients with stable glaucoma and ocular additional clinical space is provided for and other neurological conditions. more comfortable in those suffering from hypertension on treatment. Optometry, which would release existing space for Ophthalmology. Developments Visual Stress. This service was not previously The Department’s proudest achievement in available anywhere in Gibraltar or the South Low Vision Service The Optometry department aims to continue 2014 was its formal accreditation as a Teaching of Spain, which meant that patients had to This is a service for patients with visual developing services for those most in need and Placement Centre for Undergraduate fly to UK for assessment. impairments to maximise their full visual unable to communicate any visual problems. Orthoptists. In early 2014, two representatives potential with both spectacles and different This will involve developing eye care services from the Educational branch of the British & low vision aids. Low vision aids are issued in the areas of dementia, stroke, mental health, on a loan basis, and general advice is vulnerable adults and children. provided to aid rehabilitation and blind and partially sighted registration is discussed and 5.4 ORTHOPTIC DEPARTMENT undertaken if required. Additionally patients are referred to the GHA’s Rehabilitation Background Officer for the Visually Impaired to support Orthoptists diagnose and manage a variety their rehabilitation in the community and of eye conditions, specialising in squints and their use of the Low vision aids provided. disorders of binocular vision. They assess and manage patients of all ages and work Developments autonomously as well as in multi-disciplinary The Ophthalmic Unit now benefits from a teams. The work includes: corneal topographer purchased in 2015. This • Assessing babies and young children for machine maps out the curvature of the front vision defects surface of the eye and so aids diagnosis and monitoring for progression of degenerative • Routine vision screening for children corneal conditions. it also supplements starting school in Reception year correct contact lens fitting. • Assessing patients before and after surgery A new tonometer was introduced to measure for squints intraocular pressure (ICare Tonometer). It is a hand held easy to use machine, with results • Treating amblyopia during critical comparable to the gold standard Goldmann development period in children tonometer. It does not need anaesthetic eye drops and is quick and easy to use, so • Treating adults with double vision which it is useful for all patients including those can be associated with other conditions such

SECONDARY CARE SERVICES CARE SECONDARY as diabetes, thyroid disorders, neurological SERVICES CARE SECONDARY 50 51 5.5 OPHTHALMOLOGY Needs nursery, outpatient clinics at Primary Autism Diagnostic Observation Schedule areas of communication and swallowing The Ophthalmic team continue to undergo Care, Rainbow Ward and the community. (ADOS-2). The course was held at the intervention. These include: in- house training to ensure high quality Both service streams within paediatrics have School of Health Studies and run by an standards of patient assessments, treatment benefitted from staff recruitment within the accredited trainer from Great Ormond • Joint presentations with dieticians to and better flow for patients through the time frame of 2014 and 2015. In March 2014 Street Children’s Hospital. The outcome of nursing students regarding feeding issues in department, this together with the one a Senior II Speech & Language Therapist was this training is a larger number of trained palliative care stop clinics has assisted in eliminating employed to work alongside the clinical lead personnel to assess children with autism • Teaching on the Acute Stroke Module, waiting times for patients requiring Cataract within the mainstream service and in the thereby reducing the impact on individual held by Kingston University Extractions under Local Anaesthetic. following year another Senior II therapist teams. was recruited within special needs. • Delivering a rolling programme of Nurse led clinics have continued to Autism Pathway. This department is Dysphagia training to student nurses impact on the number of patients that the The Adult service is responsible for clients with involved in the identification of a patient department is now able to attend to. This swallowing and communication difficulties -centred pathway that meets the needs of • Training staff and carers within the includes a continuous improvement in the resulting from stroke, neurological disorders, children with autism and their families from Elderly Residential Services on Dysphagia number of ophthalmic conditions diagnosed cancer, dementia and voice disorders. The diagnosis to intervention. An inter-agency management. and treated in house and an extension in the range of disorders which present can include working party has been set up to help services provided to the General Public. aphasia, dysarthria, dyspraxia, dysphonia, develop and ratify this pathway in line with • Running a “Care of voice for Teachers” dysphagia and dysfluency. Locations for this NICE guidelines and in consultation with training programme. This preventative measure is aimed at helping teachers to 5.6 SPEECH AND LANGUAGE service include inpatient and outpatient the local Autism Support Group. keep their voices strong and avoid the THERAPY clinics within St Bernard’s Hospital, Elderly Residential Services including Mount Extension of services of children with development of voice disorders. Background Alvernia, John Machintosh Wing, Calpe and special needs provision. The recruitment of This report encompasses all services Cochrane wards and community. an additional member of staff has facilitated • The clinical lead therapist for the provided by the Speech & Language Therapy an increase in the holistic, targeted speech adult service has formed part of department within the GHA. The aim of and language therapy intervention and various committees responsible for the Developments this department is to provide evidence-based support within both special school and identification of effective patient services services that anticipate and respond to the Paediatric Service Learning Support Facilities (LSF) provision within specific medical conditions. These needs of individuals who experience speech, Within this area of service provision the in mainstream. In particular, LSF service include the Dementia Day-care Facility language, communication or swallowing following new services were introduced: locations are benefitting from more and the Stroke Initiative. In relation to the difficulties. The department works in intensive and cohesive intervention that Stroke service the Speech and Language partnership with these individuals and their National Autistic Society (NAS) EarlyBird incorporates team liaison and parental Therapist was shadowed by a visiting families and with other professionals and Parent Training programmes were inclusion via weekly case conferences held stroke consultant and invited to engage in agencies to reduce the impact of these often commenced in February 2014 run co- within the school setting. discussions aimed at benchmarking existing isolating difficulties on people’s wellbeing jointly with the Occupational Therapy services for stroke whilst planning future and their ability to participate in daily life. Department. This training is comprised of Autism Triage clinics have been set up initiatives in accordance with the National a 12 -week training programme aimed at within the department. These are run by Institute of Clinical Excellence, the Royal The department is comprised of both empowering parents towards working with both senior paediatric therapists and aim to College of Physicians and the Royal Paediatric and Adult services with specialist their autistic child and helping to develop identify Autistic Spectrum Disorders early College of Speech and Language Therapist streams within each area. interaction and improve behaviour. thereby facilitating timely intervention guidelines. which is in line with good practice. The Paediatric service consists of two Audit feedback presentations to schools • As a means of extending her knowledge separate caseloads, Mainstream and Special were introduced by the Mainstream service. Attendance at yearly National Autistic base and providing specialised care to Needs with clinical leads heading each area. These presentations provided the schools Society Professional conference in UK. laryngectomy patients, in June 2015, the These services are responsible for children with the results of the mainstream audit and This enables the therapists to remain at the therapist responsible for this service took (from neonates to adolescents of 18 years informed schools of subsequent changes in forefront of any new developments in the part in a working placement within a of age)who present with communication, the referral process and service delivery on field and to improve professional contacts. leading UK hospital specialising in this area. swallowing and feeding disorders including account of this audit. diagnosed genetic and medical conditions, Adult Service Continued Professional developmental delays, learning disability, Autism Diagnostic Observation Schedule Within this area of Speech & Language (ADOS) training. This department initiated Development (CPD) hearing impairment, autism and specific Therapy the following developments were This department is firmly committed to speech and/or language difficulties. multi-agency training for staff from introduced; Speech & Language Therapy, Occupational CPD and all members of staff are proactive Service locations for these services include: in the pursuit of learning and developing Therapy, Clinical Psychology and • Providing on-going training to other Mainstream schools, Learning Support their specialist skills. This is reflected in the Facilities (LSF), Special School and Special Educational Psychology in the use of the professionals, students and carers in specific SECONDARY CARE SERVICES CARE SECONDARY SERVICES CARE SECONDARY 52 53 various academic achievements listed below; Future plans for the service This department firmly believes in the • Clinical lead in Mainstream Paediatrics collaborative approach to remediation and continues a distance learning PhD at the values working in partnership with families. University of Sheffield. During 2014 pilot Disseminating information and empowering data was collected on four children during carers is seen as a fundamental future their regular speech therapy sessions. This objective and to this end, this department is data is being used to prepare a parent committed to continue developing training training programme. programmes in the following areas: • In October 2014 the clinical lead in • Whole school training in the use of Paediatric Special Needs completed a effective strategies to support speech, distance learning masters and obtained a language and communication needs in distinction in MEd Autism at Birmingham mainstream settings. University. • Developing Dysphagia competencies in • In November 2014 the Paediatric nursing staff ,other professionals and carers Special Needs therapist also upgraded her GHA Learning in Action management • Raising autism awareness in schools and qualification to level 5. within the wider community. • In November 2014, the senior II • Other major future plans involve: paediatric therapist (mainstream) attended extending the adult speech & language a training programme in UK on the therapy service to effectively meet the needs practical management of eating and of the elderly population in residential drinking difficulties in children. This is a homes and long stay wards basic qualification in paediatric dysphagia management, accrediting and equipping the • Working towards the establishment and 5.7 MENTAL HEALTH SERVICES The long awaited migration to the 52-bedded therapist to become involved in the GHA ratification of a recognised care pathway for The main focus during 2014 was the state-of-the-art modern facility, Ocean Views Feeding Clinic. autism. continued planning for the move to the took place on 7th February 2015. This was a new mental health facility. Although historic and truly memorable experience for many improvements have been seen Mental Health in Gibraltar. It has to be noted following the move, it is anticipated that that all the members of the team at every the reconfiguration of the services will level throughout all the departments worked eventually offer more effective clinical care diligently for many months to ensure the pathways that are integrated across acute, transition was carried out according to plans. community and residential care settings. This has been necessary to ensure that The treatment philosophy in Ocean Views service users and families are supported at all reflects a holistic approach in the diversity stages of the care journey and in the setting of its therapeutic programmes. The new that is most appropriate to their needs. treatment programmes currently being introduced are comprehensive and based on a recovery model approach, as many of the service users demonstrate difficulties in Ocean Views - New Mental a variety of life’s circumstances. Therefore, Health Facility the programmes have been designed to comprehensively address factors of emotional During 2014 preparations for the move to the well-being, social functioning, educational new facility continued. These preparations level, environmental influences, and familial included a number of discussions and issues in a therapeutic environment, where consultations with the general public, support safety and security are paramount. groups, clinical staff, service users and their families to explore and finalise the needs and The new in-patient facility now offers; requirements of the new service. SECONDARY CARE SERVICES CARE SECONDARY SERVICES CARE SECONDARY 54 55 Sky Ward ( Psychiatric Intensive Care Horizon Ward (Acute community a very difficult and distressing Clinical Psychology and Counselling Unit – PICU) admissions ward) process. A medium and longer term Department Sky Ward is a five bedded Psychiatric The opening of Horizon Ward provides a rehabilitation plan has now been developed The mental health services comprise of both Intensive Care Unit. Within this area there thirteen bedded mixed acute admissions in order to provide a treatment intervention in-patient and community based professionals, are 3 close observation rooms with en suite ward in a homely and secure environment and care package to assist service users’ re- who together provide a wide range of services facilities, 2 seclusion rooms and a Multi- which gives service users a choice of single integration into society. depending on need. In total there were Functional self-contained suite. The PICU is or double rooms. The main function has 723 referrals made to the psychology and an area specifically for service users whose been to offer care and treatment within an Rockside Flats (2 Male & Female counselling department in 2015. mental health condition requires them to inpatient setting that respects and allows Rehabilitation Flats) be treated in an environment of therapeutic treatment to occur in the least restrictive The rehabilitation flats linked to Dawn Mental Health Legislation (r(reform of the security for a brief period of time. The unit manner possible. The staff always encourage ward have been designed to assist service 1959 act) provides supportive, individualised care for and promote independence, self-esteem and users achieve independent living. They are Critical to the overall service that the GHA those whose acute episode of mental illness is personal choice as far as is deemed possible two purpose built residential flats for up offers has been the need to review and update resulting in disturbed behaviour that requires and assist the service user to take an active to 7 adults suffering from mental illness, the current Mental Health Act. This has a safe specialist environment. role in planning their own care. Very positive they operate on the basis of single gender presented some challenges due to Gibraltar’s feedback has been received from a number occupancy. The flats offer communal sitting uniqueness. During the review period the Multi-Functional Suite, (MFS) of service users and their carer’s as to the area, kitchen and bathroom. multi-professional Mental Health Act group The MFS is composed of two single rooms general environmental improvements, but has continued to meet on a regular basis sharing communal areas. This completely in particular to the unprecedented freedom Sunshine Ward (Elderly Mentally Ill and is at the final stages of completing this independent suite now provides a safe and of movement now possible due to the new (EMI) ward) 14 bedded unit important piece of work. A Command paper secure environment to care for service users, layout of the facility. The EMI Unit has been designed to cater was published in February 2015 for public who for specific reasons are unable to be for 3 specific areas for old age patients. It consultation. It is expected that the new nursed on the main acute admissions ward. Dawn Ward (Rehabilitation ward) offers 4 assessment beds where service users’ Mental Health Act will be in place by 2016. These service users may include children or 13 bedded unit mental states can be assessed and diagnosed. adolescents, vulnerable adults, mothers and Patients suffering from enduring mental There are 9 beds for longer term service Community Mental Health Team baby or forensic cases. illness can often find returning to the users who fall into the Elderly Mentally Ill There have been a number of changes category, (these are service users who have in this department. This includes an symptoms of a Dementia type illness and increase in psychiatrists, an increase in also have residual psychotic symptoms). clinic appointments and the completion of a full refurbishment programme to the The ARC (Activity and Rehabilitation Community Mental Health department Centre) based at Coaling Island. This was achieved This is a two floor department attached with minimal disruption to the running of to the main building that houses a variety clinics and services provided by the team. of facilities and resources staffed by a team Following the official opening on the 24th composed of occupational therapists and September 2014 , very positive feedback has nursing staff. Their main aims are the been received from service users, relatives and assessment and development of personalised members of the public embracing the new programmes in partnership with the Mental therapeutic and welcoming environment. Health Multi-disciplinary team. This service now offers both in and out patients support in Training completed in 2014 – 2015 learning new skills depending on the service Training is always high on the agenda within user’s specific needs. The ARC offers facilities the mental health services and is viewed for service users to engage in a variety of as an integral part of service delivery and events, outings, activities, personalised work service improvement, which everyone strives or groups covering a wide range of interests for. Mandatory training within mental health such as arts & crafts, photography, IT skills, is provided in-house by our own staff from gardening, cooking and pamper groups. 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 SECONDARY CARE SERVICES CARE SECONDARY SERVICES CARE SECONDARY 56 57 Clinical incidents Electronic Health Records The mental health service reviewed and A multi-disciplinary mental health group implemented their policy to prevent the risk have been working in the implementation of falls. of the GHA’s Electronic Health Records program. Work has included a visit to a Developments in 2015 number of clinical sites in Portugal and the United Kingdom, and to see how the Multi-Function Suite (MFS) software packages are being used. The MFS formed part of the new reconfigured plan for the service. Throughout the year, Future developments for the service this new unit has been used to facilitate the care needs of young adults, forensic cases, • Explore the possibility of introducing vulnerable adults, pregnant women and sheltered employment within the facility also as a step-down from the more intense • Develop the ‘Child and Adolescent Mental nursing input found in the PICU area. Health Services’ (CAMHS).

Rockside flats • Continue to develop community services. These flats have been in constant use and have • Continue with the work for introducing assisted patients in developing existing skills the new mental health act. or learn new ones in order to complete their rehabilitation and eventual reintegration into •Introduce the Electronic Health Records the community. program for the Mental Health Services. • Explore the possibility of implementing Development of groups and activities ‘Star Wards’ across the service. in addition to ARC In addition to the facilities provided by the ARC, group activities have been developed in Support, Infection Control, Mentorship, This resulted in an improved access for all three wards. These activities which include Safeguarding Adults at Risk and Tier one service users with respect to dental, optical weekly meetings in order to discuss and plan and two Child Protection. This is important and dermatological problems. Members of activities such as arts and crafts, mediation, to provide holistic care which focuses on the Multi-disciplinary team also participated indoor gardening and social inclusion groups recovery. in an exhibition promoting Dementia as well as community based outings have care, Child-Line and Clubhouse at John been positively received throughout the year by service users and their families who see 5.8 DEVELOPMENTS IN 2014 Macintosh Hall. the positive impact this has on recovery. Preparation for the opening of Ocean Views Training Apart from mandatory training, a number of Enrolled nurses and NVQ 2 and 3 In preparation for the much awaited move, a other training opportunities were taken up During 2015, six nursing assistants migration plan was identified which focused by staff. These included Venepuncture and successfully completed their enrolled nurse on teams taking responsibility to ensure it Cognitive behaviour therapy, and NVQ2 training. A further group of nursing assistants was seamless. A review and development training. started their NVQ 2 training which once of a number of mental health policies took completed will assist them in accessing place in preparation for the move. Fire Safety Management Plan enrolled nurse training. A new Mental Health fire safety management Improved collaboration plan has now been completed. It was drafted Registered Mental Health Nurses As part of the service development and in conjunction with the UK specialist Two local students who have completed responding to patient needs, a number (Tenos), the Gibraltar fire and rescue service their mental health training in UK returned of meetings was set up with other service and a small working party from the mental to Gibraltar and commenced employment provides both within the GHA and those health services. Part of this plan involves fire with the GHA Mental Health Services. outside in order to improve access for prevention training and evacuation strategies patients with mental health difficulties who for the new Mental Health facility. found it challenging to access these services. SECONDARY CARE SERVICES CARE SECONDARY SERVICES CARE SECONDARY 58 59 Gibraltar. Oncology multidisciplinary teams power means action. The Cancer Services meet with clinicians and the palliative care department together with the Health team regularly. A draft Cancer Strategy is Promotion team plan to organise various already in place, which includes new services cancer group specific awareness campaigns in that will soon be developed for patients. This order to provide information to the general will include a Chemotherapy Suite, where public and dispel some taboos. patients will be seen by an Oncologist, given their chemotherapy and followed-up post- Further developments in Cancer Services treatment. Improvements to the service has will involve the development of policies and also included the electronic standardisation guidelines in order to address some of the of all suspect cancer referrals, as per the new difficulties encountered by patients and their 2015 NICE guidelines. relatives such as Social Policies.

Part of the service provided by the Cancer Palliative Care Co-ordinator involves working with the The Gibraltar Health Authority’s Palliative Health Promotion Officers to raise awareness Care Team’s role is to ensure that patients and as to prevention, screening and symptoms to carers with palliative care needs are assessed, look out for before going to your GP. The supported and cared for appropriately. main objective of this is to diagnose cancer Palliative care nurses work closely with at the earliest stage possible in order to multi-disciplinary teams following referrals improve the chances of a successful outcome. for care and regularly liaise with other The GHA in partnership with local Cancer agencies and other Health Care providers to charities continue to work on initiatives ensure continuity of care for palliative care to get these important messages across to patients. 5.9 BED MANAGEMENT to make the patient’s cancer journey as the community. Knowledge is power and St Bernard’s Hospital continues to experience seamless as possible, offering advice, support high bed occupancy for adult patients during and a range of options. To this end, the this period. Additional beds have been used new Cancer Services Department aims to in order to ensure that beds are available improve the patient experience and improve for emergency and elective admissions. This cancer outcomes. has resulted in minimum elective surgical cancellations. This has been possible due The Cancer Services Department was to the proactive approach by the GHA’s developed in September 2015 with the multi professional Bed Management Team recruitment of a new GHA Cancer Services who continue to address the challenges by Coordinator. This new role entails the supporting and improving patient flow in coordination of services between the different order to have timely discharges. cancer service providers such as primary, secondary, tertiary care and palliative care, Victoria Ward continues to utilise its day together with local cancer charities, to ensure room for rehabilitation patients. best practice in access to cancer services and active case management. By liaising with Bed management meetings continue to all service providers, the Cancer Services incorporate Sister’s & Charge nurses in the Coordinator identifies any gaps in care and format. This continues to be welcomed as implements any possible improvements first hand input on current & future dynamics to GHA services such as new patient care can be discussed in a mutually supportive pathways, policies and protocols. This manner. new role encompasses managerial, quality assurance and educational responsibilities. 5.10 CANCER SERVICES A diagnosis of cancer can have a major impact Progress so far has included improved on many areas of a person’s life. They may communication between service providers, be dealing with many medical, emotional and there is also an established link between and financial issues. The GHA endeavours senior clinicians both in and outside SECONDARY CARE SERVICES CARE SECONDARY SERVICES CARE SECONDARY 60 61 This also includes supporting staff across Blood Donation Room the GHA and with other agencies, advising The new blood donation room which was and assessing patients when required and completed during2013 has been a success coordinating the discharge planning to with blood donors feeling comfortable and enable patients to get back to their own happy with it especially having the television homes whenever possible. for entertainment whilst donating blood. The department has also acquired a new 5.11 OUTPATIENT SERVICES computer system, new electronic scales and Blood Department trolleys. Venepuncture training for Nurses The department has started a new initiative Department of Medicine in collaboration with the School of Health The Department of Medicine comprises Studies to train nurses in venepuncture of 4 full time consultants and 6 Non- techniques. A total of 30 students have Consultant Hospital Doctors. There has completed this programme. been an additional part time cardiologist with 4 sessions per week and a full time There has been very good feedback from cardiac physiologist. students and the School of Health Studies. The main services offered by the unit The Phlebotomy department has seen an includes General Medicine, Gastroenterology, increase in attendance with clinic numbers Geriatrics, Endocrinology and Respiratory for 2015 reaching over 24,000 patients. Medicine The services offered are also complimented by a comprehensive Visiting Consultant

programme. This includes Cardiology, • Phlebotomy Rheumatology, Pulmonology, Respiratory Physiology Haematology, Neurology, As a result of the recruitment of the Gastroenterology and Nephrology. cardiologist there have been several services that have been repatriated. These have The unit also offers a variety of investigations. included in-house Echocardiography, Stress These include; echocardiography and pacemaker checks. Stress test, stress echo, Trans Oesophageal Echocardiogram (TOE) 5.12 OPERATING SUITE Operating Theatres • BP Monitors The Gibraltar Health Authority in • Sleep studies collaboration with Edge Hill University are currently delivering an acclaimed academic • Spirometry module to four Registered Nurses / • Bronchoscopy experienced Theatre Practitioners based on the Surgical First Assistant role as outlined • Endoscopies (gastroscopy and by the U.K perioperative Care collaborative. colonoscopy) The course will cover a number of topics • Bone marrow biopsy including the legalities of the role, risk assessment, principles of the role from draping, • Anti TNF (biologics) injections positioning, tissue retraction, assisting with haemostasis and electro surgery. • Pacemaker check • EEG Future training opportunities will include Operating Department Practitioner training SECONDARY CARE SERVICES CARE SECONDARY SERVICES CARE SECONDARY 62 63 • Maternity dealt with under the one area. This differs from the UK where the wards are divided • Accident & Emergency Department into antenatal, labour and postnatal care. Our unique environment allows both the women • Ambulance Services and staff to establish a relationship from the • Radiology Department onset of the pregnancy, thus enhancing the fact that the team can not only provide one • Dialysis to one care but also continuity. • All Wards & Clinics in SBH The team take pride in knowing that Midwifery colleagues who have visited • PCC the unit from the UK have always been • ECA impressed and even a little envious of the fact that the GHA offers this standard of care to • Ocean Views our women. • HMS Prison Women are waiting longer until they start their families and women with complex • RGP & City Fire Brigade medical histories can now become pregnant due to medical advancements. The team has • St Johns Ambulance recently commenced an antenatal register for all women with complex medical conditions. 5.13 WARDS AND DEPARTMENTS An MDT group has been developed to Maternity Ward manage these cases. Pre-planned care for The Maternity unit in Gibraltar is unique these women is designed to safeguard their in the fact that all aspects of Midwifery are deliveries.

which will be delivered in cooperation with The Day Surgery Unit continues to the School of Health Studies. In the past, all undertake on average 85 – 95% of all elective Operating Department practitioners have patients requiring surgical procedures of all been trained and recruited from the United sub specialities. Kingdom as it has not been possible to do so locally. Pain clinic / infiltration sessions also continue to be undertaken as well as Cardioversions The Theatre Nursing Team together with and Plastic Surgery procedures. the Medical Director, Surgeons and the Anaesthetic team continue to work to TSSU Department maximise Theatre capacity and productivity With the increase of elective Day Surgery and undertake additional theatre lists procedures and the increase of theatre such as for Visiting Consultants, Special sessions, TSSU / CSSD has had to undergo needs Dentistry and Ophthalmic General modification and development of its services Anaesthetic lists. at many levels.

Day Surgery The Department has recently undergone The Day Surgery unit continues to expand refurbishment and updating of its Steris its services and the number of procedures automated washers and decontamination undertaken within the unit with the units to enable it to continue to provide a introduction of General Anaesthetic streamlined service to other departments operating sessions to reduce the waiting list which include: for patients requiring Dental / Max-Fax • Operating Theatres surgical procedures and General Anaethetic General Surgery. • Day Surgery Unit SECONDARY CARE SERVICES CARE SECONDARY SERVICES CARE SECONDARY 64 65 John Mackintosh Ward staff aim to encourage patients to reach their The General Medical unit in St Bernard’s optimum potential which will enable them Hospital offers care for adult patients with to return home or function within their care a variety of complex medical conditions. As environment. 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 Ward Victoria 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

Ward attenders seeking advice to any queries Rainbow Ward have also increased. Staff prides themselves knowing all aspects of the service are readily The service offers paediatric inpatient, available. outpatient and ward attender facilities. The Unit comprises of three Paediatric The Care Audit proves that on the whole consultants working on a rotational basis, the women and their families are generally sixteen paediatric nurses a part time extremely satisfied by the level of care Paediatric diabetic nurse specialist. received by the team and service. Nevertheless the team know that there is always room for During 2015 the unit commenced the improvement. development of the ward attender service to include 24 hour ECG monitoring and New initiatives underway are; increased the Skin prick testing service. • The development of the early The Critical Care Unit (CCU) pregnancy unit The Critical Care Unit comprises of 10 beds • Miscarriage and neonatal services. which include 3 side rooms and capacity can be increased to a maximum of 13 beds in • A Venous Thromboembolism pathway extreme situations. All admissions are patients for high risk women based on NICE who require Intensive or High Dependency guidelines. care. The unit is overseen by three Ward Managers and a Consultant/Intensivist. • Diabetes in Pregnancy SECONDARY CARE SERVICES CARE SECONDARY SERVICES CARE SECONDARY 66 67 6.1 PATHOLOGY Beta 2-macroglobulin (B2M) used as a tumour marker for some blood cell cancers. Introduction B2M helps to evaluate the prognosis of The Department of Pathology provides cancers such as multiple myeloma and a wide spectrum of services including lymphoma. Biochemistry, Haematology, Transfusion 6. DIAGNOSTIC SERVICES service, Microbiology, Histology, Cytology and Anatomical Pathology. It is also Accreditation for the Department of responsible for the provision of Public Pathology Analyst services. The department provides a In its purpose to produce European very diverse range of tests and is excellently Standards Compliant blood components, equipped with the latest analyzers using the Department commissioned an audit best practice methods. Processes are of its Blood Donation and Transfusion quality assessed and the staff participate services. The audit assessed current blood in Continuing Professional Development bank systems against ISO 15189 (Medical which is a requirement to remain registered Laboratories) Standards. This was the first with the Health and Care Professions step and the department will now proceed to Council and other professional bodies. follow the processes necessary to attain ISO 15189 accreditation. Developments in 2014 and 2015 Performance on external quality assurance Carbapenem-Resistant schemes which include comparisons with Enterobacteriaceae (CRE) screening hundreds of laboratories, demonstrates that CRE are bacteria that possess high levels of the department performs excellently. This provides confidence to professionals both resistance towards many types of antibiotics, inside and outside the department that it including those that are a last resort for such provides quality, evidence-based services. infections. The department has implemented a CRE screening programme to test patients There is on-going change in Pathology who arrive from external hospitals. This services and the department aims to keep up ensures that any positive patients are treated to date and provide cutting edge tests that with appropriate levels of isolation, especially often are not available routinely even in much in locations such as hospitals and elderly care larger laboratories, such as full spectrum homes that care for immunocompromised Tumour Marker panels, full allergy screens patients. The availability of PCR technology and Polymerace Chain Reaction (PCR) means that results are available rapidly. analysis for microbiological identifications. These are just some of the introductions and The department places great importance on improvements over the period 2014-2015; education and development, both for staff as well as students that come to visit from Introduction of new tests schools, and those that spend time training A range of new tests have been introduced on honorary placements. The department’s to provide a better service to clinicians for outreach programme includes participation diagnosis and patient management. These in the Careers Fair where its stand is always include; popular and where members of staff promote Biomedical Science ensuring there is interest Brain Natriuretic Peptide (BNP) which in the profession in Gibraltar for the future. provides a useful adjunct to routine assessment for differentiating acute heart Future developments and plans failure from other causes of breathlessness Pathology Services are essential to the delivery of effective and safe healthcare. The workload Haptoglobin, used primarily to help detect and continues to grow and is almost 130% higher evaluate haemolytic anaemia and to distinguish than when the department moved from the it from anaemia due to other causes old hospital to this one reflecting the greater DIAGNOSTIC SERVICES DIAGNOSTIC 68 69 use of pathology services in healthcare. The department provides diagnostic services including interventional procedures such An area in which the department is planning as image-guided biopsies and therapeutic to work on this year in order to improve our services including interventions such as services is the development and expansion of image-guided drainage of abscesses are also the Laboratory Information System to enable offered. easier test requesting and result accessibility. Developments 6.2 RADIOLOGY SERVICES Installation of a new 128-slice CT scanner Background with the latest dose reduction technology The Radiology Department provides a has led to a significant reduction in radiation clinical service for patients of all ages. The doses and has increased the range of Radiology department collaborates with studies that can be performed locally. The all clinicians across the organisation in all department is now able to provide a modern specialties to review patient care and share CT angiography service and has 3D CT clinical expertise through a multidisciplinary colonography capability which has enhanced approach. the colon cancer screening programme. The Department consists of a team of In early 2014, the breast screening Radiographers, Radiologists, administrative mammogram interval was changed to two staff and assistants who are together years for all women between 40–70 year responsible for the capture, interpretation olds. This was as a result of a review of the and reporting of images from various parts existing programme and has led to a more of the body. targeted service. Ladies over the age of 70 still have the option to participate in the

programme. waiting time has reduced to 5 weeks, with A Familial Breast Cancer Screening clinic urgent scans been performed usually within has also been established. This caters for two weeks of the request. individuals with higher than normal risk The department was part of a multidisciplinary that requires more frequent breast screening team who developed a patient pathway for as well as genetic testing. the management of persistent low back pain. This included an educational section on the An Abdominal Aortic Aneurysm (AAA) imaging of back pain. screening programme was established in collaboration with the Public Health The department established an Image Department and commenced in May 2015. Exchange Portal (IEP) which is a network The programme aims to reduce deaths due set up for the secure digital exchange of to AAAs amongst men aged 65 and over. A Radiology imaging information between simple painless ultrasound test is performed St Bernard’s Hospital and UK hospitals. It is a fast, efficient and secure method that to detect AAAs and the results are provided eliminates the need for production and straight away. transfer of patient radiology images via CDs One major development has been the to the UK for tertiary referrals or expert establishment of a tertiary Consultancy opinions. service with Radiologists at St George’s A new GE Voluson 8 Obstetric ultrasound Hospital via an electronic link. The benefit of scanner enables capture of images of high this is that the GHA can now obtain expert quality, allowing the sonographers to work opinions regarding complex cases. more efficiently, and thus lowering the recall The Department has been targeting waiting rate and conforms to NICE Guidelines.

DIAGNOSTIC SERVICES DIAGNOSTIC lists in ultrasound services. Routine scan SERVICES DIAGNOSTIC 70 71 Future The 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 7. THERAPY SERVICES 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 Governance The 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. DIAGNOSTIC SERVICES DIAGNOSTIC 72 73 7.1 PHYSIOTHERAPY SERVICES Mental Health Multi-Disciplinary Team. There are joint Programme in 2014. This is a specific The Mental Health OT Team moved into OT/Physiotherapy weekly groups and daily programme run with the parents of children The department’s vision is ‘Physiotherapy the new Activity and Rehabilitation Centre individual sessions for stroke patients. under 5yrs and newly diagnosed with works’ across the spectrum of GHA (ARC) at Ocean Views in early 2015. The Autism. It is designed for the parents, to help provided services. new environment has purpose built facilities The development of an Equipment Criteria them with understanding and giving them which means that a higher quality service Document and Pathway in 2015 has coping strategies to implement at home. The Developments can be provided to both residential and improved the management of equipment in course runs twice a year and the feedback the department. AHP Stroke Pathway community mental health patients. The team from the families who have participated has provides daily activity timetables with a wide been extremely positive. A comprehensive multi-disciplinary team The Hand Therapy Service continues to have range of therapeutic, individual and group review of a researched based approach to increasing referral rates each year. The clinic activities in a variety of settings. The OTs The OTs have developed a new system Strokes was conducted. runs twice a week and provides assessment also provide relaxation sessions for Cardiac for children in First Schools who have and advice for upper limb conditions which Rehab and Bruce’s Farm, as well as a Coaling been identified as having handwriting Multi-disciplinary team Spinal Pathway may include the use of aids/splinting/ Island Lunch Group. or fine motor difficulties. This is a ‘90 day for the Management of the Patient with exercise and preventative care. Chronic Lower Back Pain programme’ with the work to be continued in school and support given to the teachers Community Paediatric and parents. This is in line with NICE Guidelines and The Community OT team have a triage OT referrals for children both pre and post a was completed and implemented. system for OT referrals in order to allocate diagnosis of Autism (0-18yrs) are increasing. Attendance to the Sensory Integration appropriate priorities and manage the The addition of a Physiotherapist working This has seen a higher number of referrals Conference (2015) and completion of training demand as effectively as possible. in the Spinal Clinic will improve the Spinal from mainstream schools and learning for the Autism Diagnostic Observation Schedule (2014) has enhanced therapists’ skills Pathway further. An OT with a special interest in Palliative support facilities. This has placed additional and enabled further service development. Care now works closely with the Cancer demands on the services offered. Clinical and Quality Audits Relief Centre, providing continuity of The OT and Speech and Language Therapist An internal review of GHA Physiotherapy care and one point of contact for palliative completed the first Early Birds Training Services was undertaken and covered areas of patients requiring OT input. Clinical Governance. This will form the basis of developing Physiotherapy in 2016. The wheelchair assessment service now has direct links with a specialist wheelchair clinic 7.2 OCCUPATIONAL THERAPY in Malaga, which enables joint working with the GHA OTs to achieve individual needs- Background led assessments for the provision of specialist The GHA Occupational Therapy (OT) wheelchairs. department covers Community, Paediatric, Mental Health, Secondary care in-Patient and Rehabilitation for the Visually Visual Impairment Services. The department Impaired provides a wide range of services across the This service continues to develop with the above specialities which include adults and OT assessing and providing rehabilitation children. It aims to enable function and for people with low vision or visual independence through person-centred and impairment. This is a service which provides holistic assessments. an holistic assessment of the person and how they function in everyday life. It Service Developments includes providing training with the use of The OT department was involved in some aids/equipment, and understanding of the major building projects around Gibraltar. person’s psychological and emotional needs. The aim of this was to act in an advisory The OT also supports and advises carers and capacity to ensure the new buildings are facilitates modifications to the home. accessible, not only for those with physical disabilities but also sensory impairment. This St Bernard’s Hospital gives them a good quality of life, which The OT department continues to work on facilitates independence in their own home the Stroke Initiative Pathway to benchmark and access to public facilities. This work was the current service using the UK NICE highly valued by the architects and building

PHYSIOTHERAPY SERVICES PHYSIOTHERAPY guidelines, with the other members of the SERVICES PHYSIOTHERAPY companies involved. 74 75 7.3 NUTRITION AND DIETETICS Weekly paediatric feeding clinic in The department of Nutrition & Dietetics conjunction with the speech & language provides advice about nutrition and diet in therapist relation to health and illness, helping people to understand the impact of diet on their Outpatient paediatric diabetic clinics every health. 3 months (multidisciplinary) The department’s aim is to assess nutritional Monthly input to St Martin’s special school. status and offer effective dietary treatment for nutrition related diseases by using evidence Multidisciplinary team working based practice, education and support. Monthly palliative care meetings Staff in the department consists of 4 Regular MDT case conferences. registered dieticians based at St Bernard’s Hospital providing a service to in patients, Education and Health promotion out patients and in the community. Teaching sessions to a range of staff groups All dieticians have developed particular areas Public health nutrition - advice and of expertise and offer a wide range of dietetic talks/workshops to schools and other services. organisations. Nutrition & Dietetic Services include: Developments Inpatient services One of the new developments has been the involvement of the Paediatric Dietician in Daily inpatient services (adults and the Autism Working Group, which meets on paediatrics) to all wards, including a monthly basis. One of the first objectives intravenous and nasogastric/gastrostomy identified by this group is the development feeding of an Autism Pathway which will include a Parent Information Pack. Head Pharmacist, one Dispensary Manager, disciplinary meetings and patient work Assessment of renal/dialysis patients three Clinical Pharmacists, one Basic Grade groups. The department has seen an increase in Pharmacist, three clerks and one labourer. Visits to Ocean Views hospital to assess referrals for the Enhance Recovery After The Pharmacy Department was refurbished patients Surgery scheme (ERAS) for patients Expenditure on drugs and pharmaceuticals and extended in 2015 to accommodate new undergoing colo-rectal surgery. Patients on continues to grow as a result of higher bed working areas and administration offices Outpatient services the ERAS scheme have dietetic input as an occupancy levels, increased medical and which has led to improvements to the general 5 adult outpatient clinics per week out-patient pre-surgery and as an inpatient surgical services and the introduction of layout of the department. post-surgery. new vaccine programmes such as the new 1 specialist Gastroenterology clinic per Clinical Pharmacists carry out regular week. Hepatitis B vaccine. visits to the acute wards providing valuable 7.4 PHARMACY Ocean Views Hospital continues to benefit pharmaceutical advice to both health 1 drop-in weighing clinic per week The Hospital Pharmacy provides pharmacy from regular monthly visits by a pharmacist colleagues and patients. services to the GHA and external agencies Weekly cardiac rehab (clinics and talks) as who attends doctors’ ward rounds, multi- part of the cardiac rehab team such as the Elderly Residential Services and HM Prison. Home visits following health professional’s referral (including Elderly Care Agency, The Hospital Pharmacy is responsible for Cancer Relief Centre, Dr Giraldi Home, St the purchasing, importation, stockholding, Bernadettes) distribution and dispensing of drugs and pharmaceuticals and other medical and Paediatric services surgical appliances. 2 outpatient paediatric clinics per week The Pharmacy team is composed of one PHYSIOTHERAPY SERVICES PHYSIOTHERAPY SERVICES PHYSIOTHERAPY 76 77 8.1 LICENSING OF DOCTORS Medical Council to be recognised under Background British Law as a “Suitable Person” who would The Gibraltar government elected to have lawful authority to advise the Council office in December 2011 had a manifesto on the revalidation of doctors. Gibraltar Law commitment to restructure the regulation of was changed accordingly. doctors. It stated: 8. IMPROVING QUALITY OF CARE Responsible Officers “We will outsource to the GMC the In most organisations of the NHS, the assessments of doctors of licences to practice: Responsible Officer is usually its Medical and will make the GMC the regulatory body director, because roles and responsibilities in in Gibraltar for the medical profession, so term of governance of doctors do overlap. In that its standards, rules etc. apply in Gibraltar the GHA, however, the roles were separated as they do in the United Kingdom.” to enable the Responsible Officer to develop GMC refers to the General Medical Council, this new role without distraction and a the statutory body that regulates doctors in separate post was created. the United Kingdom. To fulfil the manifesto The Responsible Officer carries out the commitment, the Government enacted a following functions: new law, by which all doctors who wish to practise in Gibraltar must be in possession of 1. ensuring that there are systems and a valid Licence issued by GMC. processes in place locally to support doctors in their revalidation, such as The Licence is what gives a doctor the legal annual appraisals; authority to undertake medical duties, such as examining patients, prescribing medicines, 2. monitoring the conduct and providing treatments and signing death professional behaviour of doctors, certificates. Doctors who do not have a and overseeing any fitness to practise Licence cannot carry out any such activities. procedures; and 3. making recommendations to the Revalidation GMC about the revalidation of Licences are issued by the GMC usually doctors who have a prescribed for five years and when the Licence connection with him. expires, it must be renewed by a process called Revalidation. The GMC makes the In November 2014, Dr Safwat Tosson was decision to revalidate a doctor, based on the appointed by the GHA as its Responsible recommendation of a senior doctor called the Officer Responsible Officer (RO) appointed by the Suitable Person doctor’s employing organisation. However, A Suitable Person in British law is a licensed this structure is limited by law to the UK doctor who the General Medical Council has mainland and has no validity in Gibraltar. ·approved as suitable to make a revalidation The Minister for Health set up a Revalidation recommendation about a doctor’s fitness to group, which included leaders from the practice in the same way as the Responsible GHA, the Medical Registration Board Officer. and the Medical Advisory Committee, to The General Medical Council has strict explore strategies to meet the challenge of criteria for the selection and approval of a revalidating doctors working in Gibraltar. Suitable Person. In order to achieve the status The Government also consulted with of Suitable Person, Mr Tosson was required the General Medical Council and the to attend Responsible Officer Training in Department of Health. the UK and must remain an active member It emerged that the way forward was for of the network of Responsible Officers. The Gibraltar law to enable the GHA to establish Suitable Person is also required to adhere to its own Responsible Officer. The appointee the GMC reporting guidelines. would then be able to apply to the General In February 2016, Mr Tosson was recognized IMPROVING QUALITY OF CARE QUALITY IMPROVING 78 79 by the General Medical Council as a Suitable ensure that the public can continue to have Person under British law. confidence in their doctors at all times and that doctors remain motivated to maintain Appraisal framework high standards of care for their patients. In order to make recommendations to the GMC about each doctor’s fitness 8.2 SAFEGUARDING ADULTS for revalidation, the Responsible Officer AT RISK primarily relies upon the Medical Appraisals The GHA’s Safeguarding Adults at Risk completed by the doctor once every year Team work in close liaison with the Care during the Licence period. Agency and other organisations to make Medical appraisal is a process of facilitated Safeguarding everyone’s business and to self-review, in which, once a year, the doctor ensure GHA staff have full knowledge uses protected time to meet with a trained and understanding of safeguarding external appraiser, in order to focus and reflect procedures and how to act when abuse is upon the full scope of his or her work and suspected. Abuse can be physical, financial, how it complies with the GMC’s model of psychological, institutional, discriminatory, Good Medical Practice. It includes a review sexual or neglect/omissions to Act. of professional development, regular training, feedback from patients, any complaints and The team’s aim during this period has been to evidence of quality improvements. maximise training across all GHA disciplines The outcome of each appraisal is sent to ensure registered practitioners are aware to the Responsible Officer. Just before a of their responsibilities to act and report. doctor’s Licence reaches its expiry date, the Responsible Officer summates the Reports of abuse have increased from 4 in previous five years of appraisals and makes a 2012/2013 when reporting began to 7 cases recommendation to the GMC, as to whether in 2014 and to 14 cases in 2015. A proportion or not the doctor should be granted a Licence of these are identified through A&E or in for another five years. the community. The increase in numbers mainstream European ombudsmen schemes. website (www.ombudsman.org.gi). probably indicates greater awareness and To setup the process of annual Medical reporting. It demonstrates that the training The Ombudsman is a full voting member The Ombudsman is embedded in Gibraltar’s Appraisals in Gibraltar, the GHA established GHA staff are receiving is helpful in raising of the (British) Ombudsman Association Constitution and is an Officer of the a contract with Health Education Wessex to such awareness and encouraging reporting. (“OA”) as well as of the International . The Ombudsman undertake the appraisals of all GHA doctors. Ombudsman Institute. It also forms part of enjoys the highest degree of independence The GHA also subscribed to the Revalidation the European Network of Ombudsmen. The and is respected as such by all entities under Tool Kit as an electronic platform to support 8.3 COMPLAINTS HANDLING Ombudsman takes a very active part in the its jurisdiction. revalidation. SCHEME OA First Contact Interest Group where it Complaints against the Gibraltar Health Specifically in respect of complaints GHA doctors have embraced the appraisal is a leading member. It also cooperates in Authority are received and investigated by the Legal Interest Group and is currently against the Gibraltar Health Authority the process enthusiastically with 100% of GHA the Complaints Handling Scheme (Health) Ombudsman, pursuant to an agreement doctors completing their appraisals in the exploring means of setting-up an Overseas which operates under the auspices of the Members Interest Group. with the Parliamentary and Health Service very first year, a record even in the UK. Gibraltar Public Services Ombudsman. Ombudsman, in the United Kingdom has All investigators are trained and have obtained direct access to the same clinical advice Future certificates in Ombudsman and Complaint as that enjoyed by the said Parliamentary Given the complexity of the changes, at Background Handling Practice from Queen Margaret Ombudsman and all other public sector the time of promulgating the new law, the The Gibraltar Public Services Ombudsman University in Scotland. Ombudsman in the United Kingdom and Government provided for an 18-month (“Ombudsman”) was brought into existence Ireland. transitional period for doctors to become upon the enactment by the Gibraltar Parliament of the Gibraltar Public Services The Ombudsman has a statutory duty to compliant with the new requirements. By report to Parliament on an annual basis its Ombudsman Act 1998. The Scheme January 2017, all doctors working in Gibraltar activities and all the investigations it has The Government of Gibraltar in its 2011 will have to possess a Licence to practise carried out during the preceding calendar Since 1998, the Ombudsman has constantly election manifesto stated that all complaints issued by the General Medical Council. year. Its Annual Reports, together with a kept its operating standards under review against the Gibraltar Health Authority would It may seem somewhat elaborate and complex, with the result that at present, the services it plethora of information into the work of the but the aim of this entire framework is to offers is at par with that being offered within Ombudsman in Gibraltar can be found in its IMPROVING QUALITY OF CARE QUALITY IMPROVING OF CARE QUALITY IMPROVING 80 81 be dealt with directly by the Ombudsman. Its role is to: Whilst the Ombudsman welcomed this as a vote of confidence in the Ombudsman and Provide a dynamic, sensitive and responsive its work, he also made known to the newly complaints handling service elected Government that it would not be Address all complaints from service users commensurate with ombudsman philosophy to be directly involved ab initio with Be responsible for gathering all relevant 9. SCHOOL OF HEALTH STUDIES complaints against any public body under its facts pertaining to a complaint jurisdiction. The Government of Gibraltar accepted the Ombudsman’s proposals and Conclude the fact finding exercise and consequently the Complaints Handling (where appropriate) making relevant Scheme (“CHS”) (pursuant to an arms- recommendations to avoid repetitions of length agreement) became the complaints actions leading to specific grievances portal for all complaints against the Gibraltar Health Authority as from 1st April 2015. Log all complaints and compliments The CHS is currently manned by a Implement a follow up procedure 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. IMPROVING QUALITY OF CARE QUALITY IMPROVING 82 83 The School of Health Studies (SHS) On successful completion of the BSc (Hons) offers a range of educational activities. The Nursing (Adult) degree programme, students programmes are proactive, anticipating apply for registration with the GNMHVRB. not only today’s expectations but This programme provides for the delivery tomorrow’s demands. The SHS is dedicated of University level education close to home. to advancing the health and well-being of SHS lecturers along with the support of GHA individuals and communities. Based at St clinical staff teach and assess the programme, Bernard’s Hospital the SHS offers academic external validation of academic standards are excellence to those taking their first steps undertaken by Kingston University London in healthcare as well as to practitioners and St George’s University of London. with many years’ experience in their field, creating an exciting and innovative learning The School oversees the delivery and quality environment. Students graduate equipped assurance of QCF level 2 in Health and with the employability skills they need to Social Care which now extends to a range succeed in a range of healthcare settings of GHA staff. along with the foundations for lifelong learning. Developments Twelve senior managers are in the final The School continues to provide an stages of the PGCert, PGDip and MSc in eighteen month Enrolled Nurse Programme, Leadership and Management in Health. This upon successful completion pupils apply programme concludes in 2016. for registration with the Gibraltar Nurses’ Midwives and Health Visitors Registration The SHS continues to work closely with Board (GNMHVRB) exiting the programme a number of external organisations such as with a Qualification and Credit Framework the Department of Education in raising its (QCF) level 3 in Health and Social Care.

profile and promoting nursing as a career modules are generic, encouraging staff to option in Gibraltar. accumulate academic credit as they work towards a Diploma, Degree or Post Graduate Continuing Personal Professional qualification in health care. Development (CPPD) The SHS library remains the centre within In complex, challenging and rapidly changing the GHA for information storage and modern healthcare services it is important retrieval. It provides expert assistance to staff for staff to be able to access relevant and as well as supporting the teaching, learning flexible Continuing Personal Professional and research activity within SHS and the Development (CPPD) opportunities that GHA. There is ongoing investment in the meet personal and professional needs with electronic databases as the Library advances the aim of promoting the delivery of high with the use of new technologies. The quality, safe and compassionate care that physical collection also provides our users results in improved health outcomes and a better experience for patients, families and with material to support them in their work. carers. The GHA continues to invest in CPPD for all staff within the GHA and this element Significant events of the School’s work continues to expand. The Enrolled Nurse programme of study has The modules offered are multidisciplinary been extended from one year to eighteen with the aim of engaging a wide range of months, this allows further acquisition of skills staff from across the GHA. The modules and the theory required to underpin their (utilising a range of academic levels) reflect practice. The first ever cohort of BSc/BSc local need and are closely aligned to GHA (Hons) Nursing (Adult) students graduated strategic direction in response to the needs in September 2015 and this was a landmark of the people of Gibraltar. Many of the event for Gibraltar. Eleven students graduated SCHOOL OF HEALTH STUDIES SCHOOL OF HEALTH STUDIES SCHOOL OF HEALTH 84 85 receiving their Degree in a graduation general practice, pharmacy, public health, ceremony with dignitaries and distinguished education, the armed forces and patient guests from Kingston University London and groups. St George’s University of London. Another milestone in the history of the SHS was During 2015, the SHS became an Associate that nine members of staff from the GHA Campus of the . received a Dip/BSc in Health Care Practice 10. MANAGEMENT from St George’s University of London and Future Kingston University London. The SHS is steadfast in its desire to be able to respond to the needs of the people of Gibraltar Fourteen Enrolled Nurses, the first in through the provision of high quality, fit Gibraltar, received their QCF level 3 for purpose and contemporary healthcare award along with twenty four Health Care education. It will continue to provide Assistants who also received the Health and programmes of study at undergraduate level Social Care QCF level 2 award. Four staff as well as postgraduate Masters level. were awarded the A1 assessors qualification. Twenty two members of staff received the The GHA will continue to invest in the Extended Diploma QCF level 5 Diploma development of a contemporary multi- in Management and Leadership award skills laboratory which will enable staff and at the same ceremony. These awards and students to work in a state of the art simulation the ceremonies that accompany them environment. The re configuration and re- demonstrate due recognition of the equipping of the computer suite will provide dedication and commitment staff make benefit for all GHA staff. towards enhancing the patient experience. The SHS is committed to being the best The first European Men’s Health forum provider of health care education within the Conference “Men’s Health and Primary region, strengthening our current provision Care, Improving Access and Outcomes in and ensuring the development needs of the Gibraltar” was held in May 2015. This was staff within the GHA are met. a resounding success with over 30 attendees from a wide range of settings, including SCHOOL OF HEALTH STUDIES SCHOOL OF HEALTH 86 87 10.1 SPONSORED PATIENTS Department to make the system quick, accurate and user friendly. The role of this department is to provide service to patient and escorts/families to During July 2015, the department tertiary care centres outside Gibraltar. developed contracts with various hospital accommodation centres allowing the The service offered by the department is department to book directly for patients if to provide to both external and internal they so wish. This has proved beneficial for customers. External customers are patient/ patients by removing pressures of having to families and hospitals abroad mostly in the find their own accommodation at a stressful United Kingdom and Spain. Sponsored time in their lives. The feedback on this new Patients also provide a service to internal initiative has been positive. The number departments such as the Critical Care Unit of people opting to continue with Means and hospital wards in order to carry out Testing Assessments has improved due to their tasks such as organising In-patient allowances being increased. transfers to other centres. The department also work closely with the GHA Accounts Also in July 2015, the ‘three week’ rule was section for the preparation of payment of abolished. Previously, patients had to remain invoices from the various companies. in UK if they had an appointment within three weeks. The department can now fly In November 2014, the department was people back to Gibraltar providing the time provided with a new Computer System limit of the next appointment is reasonable. which has facilitated the inputting of patient Patients over the age of 65 and those under 18 data. It is a fast and effective system. All can now also request two escorts as opposed members of staff had an input and worked to just the one, based on individual cases and closely with the Information Technology at the discretion of the Referring Directors.

10.2 HUMAN RESOURCES in January 2014. Mr Darion Figueredo was Overview appointed Unit General Manager – Hospital The Human Resources Department is Services, Mr Chris Chipolina was appointed dedicated to the recruitment, selection and Unit General Manager – Mental Health and retention of staff for all GHA departments. Mr Adam Wink was appointed Unit General The department is continually assessing and Manager – Primary Care. These new posts are developing its processes with the aim of part of the senior management re-structure improving the quality of the service provided and are pivotal in the GHA’s commitment for both internal and external customers. to sharpen its focus on the service delivery to patients. Amongst other responsibilities, the UGMs are accountable for the day to day Recruitment management of services, implementation of Recruitment activity remained constantly strategy, clinical and corporate governance, high during 2014 and 2015, more so during financial management and performance the final months of 2014 and early 2015 monitoring. with the recruitment of the additional staff for Ocean Views. Recruitment commenced As at 31st December 2015 there were a in October 2014 with interviews carried total of 1034 employees and the chart in out both locally and in the UK during the Appendix shows the distribution of the months of November and December. personnel throughout the various staffing Appointees took up their posts in January groups. 2015 in time for the scheduled opening of the new mental health facility.

Three significant appointments were made MANAGEMENT MANAGEMENT 88 89 10.3 DEVELOPMENTS and to provide a working environment that Careers Fair. The event took place on practice requirements necessary to conduct Department reconfiguration ensures as far as possible, the health and safety Tuesday 24th February 2015 and as expected, employee investigations and the techniques of all employees, patients and visitors. the GHA’s stand proved extremely popular required of the investigators. During 2014 the department carried out a with visitors as it was a great opportunity for review of its main functions and as a result Exit Interview Policy both students and parents to interact with a NHS Employers Workforce Leaders’ embarked on a process of reconfiguration, This policy has been developed in order wide cross-section of healthcare professionals Summit with responsibilities and processes being to establish an effective exit procedure for on the day. Representatives from practically The Director of Human Resources was modified with the aim of improving the employees leaving the organisation. It will every department in the organisation were invited and participated in the NHS overall service to both its internal and give individuals the opportunity to provide present assisting with queries relating to Employers Workforce Summit, held at external customers. feedback on their perceptions of the GHA training, job opportunities and career the ACC Liverpool. The summit gave The re-training of Human Resources staff as an employer and allows the organisation pathways. participants the opportunity to discuss commenced in February 2015 and relocation to gather valuable information that may strategic workforce priorities. of workstations within the department be used in modifying and developing our Workforce Planning was completed in August 2015, with the recruitment and retention strategies. This The Department continues to liaise closely NHS Confederation Annual new reconfiguration fully functional by st1 policy was introduced in July 2015. with department heads and the Department Conference & Exhibition 2015 September 2015. of Education and Training with the aim of Following on from the Leaders’ Summit, the Equality & Diversity Policy ensuring that there is a supply of qualified Director of Human Resources attended the As a result the Human Resources team has The Equality & Diversity Policy was and, where necessary, appropriately NHS Confederation Annual Conference & been split into three separate groups each introduced in July 2015 and has been experienced local applicants for all clinical Exhibition. This conference is the largest with full responsibility for specific staffing developed in order to provide a framework posts, with the aim of reducing reliance on meeting of senior health and care leaders in groups, as follows: to ensure that all the GHA’s employment overseas contract staff. the UK. The experience was highly positive policies, procedures and guidelines reflect as it was extremely valuable to network with Team 1 - Nursing Grades and reinforce the organisation’s commitment Human Resources staff, along with delegates and various HR professionals, to equality and diversity in the workplace. representatives from other areas in the during and after conference, in order to Team 2 - Medical, Dental & Ambulance organisation, continues to visit local Grades All policies will now be assessed by means of discuss common challenges and potential an Equality Impact Assessment Tool. schools with the aim of promoting careers solutions face-to-face. Team 3 - Allied Health Professionals, in healthcare and future employment opportunities in the GHA. Administrative, Industrial & IT Grades Corporate Induction Policy STAFF AWARDS The underlying objective of this policy, Since its inception in 2007 the Staff Awards This reconfiguration gives the department introduced in July 2015, is to ensure that Training Programme has been growing in popularity greater flexibility when the need to cover all new staff starting in whatever grade Foundation Level Certificate in and a very well attended 7th event took place absences in the department arises. or discipline undertakes a structured and Human Resource Practice in November 2014. A total of 106 individual comprehensive induction that will enable In 2014, two members of the HR team nominations covering 63 separate staff and Policies them to provide a safe and efficient service commenced a nine month training departments were received for consideration A number of Human Resources related within their area. programme in the Foundation Level by the Staff Awards Committee. policies were introduced during 2014 and Certificate in Human Resource Practice 2015. The Director of Human Resources, assisted Departmental Induction Policy (Level 3). This qualification provides a firm by members of the Staff Awards Committee, (Medical Staff) foundation in all areas of HR, as well as an presented the Staff Awards Ceremony, whilst Drug, Alcohol & Substance Misuse This policy was introduced in July 2015 and understanding of HR in an organisational the Minister for Health, together with the Policy its objective is to ensure that all new medical context. This policy was introduced in December staff starting in whatever grade or discipline Chief Executive and representatives from the 2014 and establishes the responsibilities and main sponsors. undertakes a structured and comprehensive Employee Investigations Law & principles behind the GHA’s approach to induction that will enable them to provide Practice managing the misuse of drugs, alcohol or Awards were presented to the winners in a safe and efficient service within their Three HR staff members attended a course other substances by employees. This policy is each category, as follows: specialist area. on employee investigations in the UK with intended to promote the general well-being the intention of disseminating the learning of all employees and to avoid unnecessary Students Careers Fair outcomes to others in the department illness, absences and accidents caused by The Human Resources Department and the organisation through structured drugs, alcohol and substance misuse. It is successfully co-ordinated the GHA’s presentations. The presentations will provide also intended to improve work performance participation at the bi-annual Students an understanding of the legal and best MANAGEMENT MANAGEMENT 90 91 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 medical history and care within the GHA. continued support and generosity towards The objectives of the Medical Records this initiative. Department are as follows:

10.4 CORPORATE SERVICES • To ensure that the right record, for the right patient is available in the right place at Records Management the right time. The Medical Records Department strives to provide an effective and efficient service • To ensure that the medical record is in the management of paper based recorded completed by all professionals in a manner patient information which represents the consistent with their expected professional systematic documentation of a single person’s standard of practice.

• To ensure records are stored safely and The Records Department continues to securely and in a manner that protects support all clinics in the appointments confidentiality. process and is also responsible for booking clinics for all visiting specialties. • To ensure the correct disposal of medical records. Front of House • To enable patients who have a right of Administration access to their records and wish to do so. A new team of GHA Clerks have been Following the relocation of the department to recruited to provide a 24 hour administrative accommodate a bigger library and further to support to the Accident & Emergency the initial file grooming, the Gibraltar Health Department. Although the primary role Authority again contracted with a service of the team is to provide a comprehensive provider to complete the file grooming and administrative support to the department, tagging exercise. The enhanced tagging including manning the reception desk, duties now incorporates the UPI, (Unique Patient also include afterhours service for retrieval of Identifier) number and RFID chips. The patients records, registration of unregistered tracking system has also been upgraded and patients and assessing non-entitled patients now allows tracking to a specific area within attending A&E. Efficiencies responding to the Medical Records library. the public and providing patient records, With the introduction of new technology registration and accounts function has been and practices, the department now includes improved due to the quick response of having a networked patient database, file tracking staff on site. There has also been a substantive software and mobile barcode readers. saving in overtime costs considering that staff MANAGEMENT MANAGEMENT 92 93 previously on on-call duties had to attend Improvements and achievements introduced when recalled in order to cover these roles. during 2014/15 include the following: Completion of soft furnishings for Ocean Domestic Services Views by our Seamstress department The Domestic Services Department are following the agreed colour scheme for each responsible for the following services: floor. • Domestic cleaning Following best practice and in liaison • Labouring services with the Infection Control Officers the department piloted and introduced • Laundry Services, including Linen disposable privacy curtains in all clinical Distribution areas. Disposable curtains eliminate both the • Seamstress Service cost and environmental impact of laundering conventional curtains. The curtains are • Refuse and Clinical Waste collection durable and have shown that they can stay hanging for a year or more, however the The new management structure now department assesses the frequency at which includes a Deputy Manager and will shortly the curtains should be changed in different introduce dedicated Supervisor posts which areas. Each curtain has a self-audit label so have been approved to cover all sites within that it can easily be audited when it was last the organization. This new structure will provide an improved and pro-active approach changed. Disposable curtains also comply to manage the operational requirements of with the same fire retardancy standard as the Gibraltar Health Authority. conventional curtains and are manufactured from a durable, disposable, and completely MANAGEMENT MANAGEMENT 94 95 recyclable polypropylene fabric which • Investigation Unit, Phlebotomy The initial feedback has been very positive. 30th June 2014 and this promotion resulted inhibits bacteria growth. Department, Operating Theatres and all The department offers a choice at point of in the promotion and additional recruitment wards. consumption which is an improvement from of staff to the department. Additionally, the The management and storage of materials the previous meal service. procurement and implementation of the has been solely devolved to this department. • Expansion of Pharmacy Department. EMIS Health Electronic Patient Record Top up service for cleaning products has (EPR) system has required much involvement • The refurbishment of all ensuite New Initiatives & Improvements been successfully introduced. from the team in both implementation and bathrooms within the wards. Pan Dulce support. Minor Works • New reinforced guttering Since the move from the old St Bernard’s The Minor Works team provides Hospital, patients have not had the traditional There are currently 100 servers, 30% of maintenance and up keep to all areas across • A temporary Ebola Unit created pan dulce but now every Christmas this will which are virtualized, approximately 650 the organization. now be enjoyed by patients. PCs and over 70 centralised networked Refurbishment of all food & beverage bays printers. A range of clinical systems currently in wards to accommodate the new bulk During 2013/14 the team have been New Menu for St Bernadette’s. in place consist of the Electronic Patient food service. involved in major refurbishment works in A new specific menu to meet the Record, Radiology, Pathology, CCU patient monitoring, Dental Xray, Endoscopy, the Primary Care Centre and Community requirements of St Bernadette’s Centre has Colorectal Screening, blood bank control Mental Health department. Catering been developed and implemented. and many more. Improvements and new works included the The new Catering Facility commenced following: Choice at point of consumption The department continuously monitors operation on 10th October 2015. A wide Patients can now choose between four main courses all of our systems across all of the sites 24 • New maintenance programme introduced range of professionals were involved in this and even order something different if desired. hours a day, 7 days a week. Warnings and for the systematic overhaul of all wards and project and without them this important alerts are sent straight to the helpdesk and departments. achievement would have not been completed Food Quality duty engineer so that problems are resolved as smoothly as it was. Food is of a better quality in general and swiftly and effectively ensuring that problems • Refurbishment of the Medical temperature control has been improved. encountered are kept to a minimum and All food provided to wards at St Bernard`s sometimes alleviated before the end user are monitored for temperature and this is even realises there was an issue in the first recorded. place. The IMT helpdesk is now handling between Environmental improvements 600 and 700 calls a month together with approximately 200 direct support ticket The new catering facility has led to requests with totals approaching 900 environmental improvements such as; support requests per month. This signifies a •Water and electricity consumption being 50% increase over the previous 2 years and reduced by at least 30% reduction in the use reflects a continued increase in the number of IT systems being introduced as well as the of batteries and carbon emissions GHAs ever increasing reliance on those IT •Eco-friendly sandwich container packs have systems, especially since the implementation been introduced. of the EPR system in June 2015. IM&T staff members are on a constant 10.5 INFORMATION programme of Continuing Professional MANAGEMENT AND Development to remain up to date with TECHNOLOGY the latest technological developments and The GHA’s Information Management & standards. Technology (IM&T) department maintains systems and networks across 5 geographically There has been the need to invest in separated sites all of which are connected via additional Server hardware to facilitate new fibre cable or wireless network links. During systems that have been implemented over the course of 2014/2015 the department the course of the two years. went through a period of substantial change. A new Director of IM&T was appointed on Many of the major projects or work streams MANAGEMENT MANAGEMENT 96 97 • EMIS Health EPR system- collaboration and it is this information and its flow that and integration of existing in house systems governs all its processes and predicates clinical not covered by the project together with outcomes. An Integrated EPR System will works streams enabling the transfer from the help the organisation improve the quality in-house systems to the new Emis Health of the service it provides, making it safer, suite of applications more patient-centred, effective, efficient and transparent. It will underpin all its clinical 10.6 ELECTRONIC PATIENT care and patient administration but also RECORD inform professional, regulatory and statutory In 2014, the Gibraltar Health Authority requirements. (GHA) embarked on arguably this organisation’s most important quality The programme commenced with the improvement initiative, the Electronic Competitive Dialogue Tender Process Patient Record Programme. The aim was to and this was the first of its time that the deliver on the Government’s 2011 Manifesto Government of Gibraltar (GoG) had Commitment on ‘the computerisation of all used this demanding and complex tender patient notes … targeted at clinical/patient need’. process. This required collaborative working The brevity of this statement does not capture between several GoG departments and the potential impact of this programme in external agencies. However, the most transforming healthcare nor consequentially significant feature was the engagement of the socio-technical challenge that the key stakeholders in this process i.e. frontline organisation faced in its implementation. clinical and non-clinical staff. They were The quality of the care is determined by the tasked with the responsibility of evaluating quality of an organisation’s communication the products, short listing the suppliers and

undertaken over the two years are: • Records tracking software upgrade from Filetracker to Filetrail completed in 2014 • EPR Project – upgrade of existing PCs and expansion/development of IT • All servers relocated to the new purpose infrastructure to accommodate the project built hospital data centre in 2014 • New Mental Health Facility- installation • Chemotherapy suite IT infrastructure and commissioning of all IT hardware. complete for opening in 2016 • Community Mental Health project – • Upgrade of aging CCTV infrastructure upgrade of all IT equipment and installation complete. Camera replacement planned for of additional hardware early 2016 • Hospital Wifi Installation - completed and • In house development & launch of to be commissioned in 2016 completely new tailor made Sponsored Patients System • Upgrade of PCs from Windows XP to Windows 7 – 95% complete. Final 5% to be • In house developed Human Resources completed early in 2016. System – work started in 2015 to continue into 2016 • Digital Dictation (Bighand) deployed across the whole of the Hospital and • In house developed Hospital stores Primary Care Centre inventory & stock control system • Intranet Site redesigned and due to be • In house developed screening software launched early in 2016 primarily for Colorectal and AAA Screening programmes MANAGEMENT MANAGEMENT 98 99 making the final recommendation on the • clinical records are not being lost 10.7 ESTATES AND CLINICAL management, major works, contracts preferred supplier. This required that they ENGINEERING management, financial control, backlog participate in the scripted demonstrations • multiple users are able to view clinical The Estates & Clinical Engineering maintenance and statutory compliance. and attend site visits to view the products records at any one time Directorate is responsible for the management in the live environment. Their involvement • clinical records can be viewed from and development of the GHA’s overall Directorate Strategy has been central to the initial success of the multiple locations Estates strategy and engineering support. The In keeping with the GHA’s new 3 year programme and their contribution cannot GHA’s estate is spread across multiple sites Strategic Plan and following GHA Board be underestimated. Four suppliers responded • prescribing alerts that include St. Bernard’s Hospital, Primary approval, the Directorate has identified the to the Invitation to Tender and two suppliers Care Centre, Ocean Views Psychiatric Unit, following 8 work streams which will be This led to the commencement of Phase 2 were asked to submit their Best and Final CMHT Unit and the Catering Facility. There critical to ensure the directorate is ready to of the programme and the planning for this Offer (BAFO). EMIS Health was selected as is also an increasing amount of equipment meet the challenges posed by an increasingly took several months with approval of the the preferred bidder and the contract signed maintained for patients in the community. flexible and technology based healthcare Programme Initiation Document by the in September 2014. system. The directorate will therefore address EPR Board in January 2016. However the The Directorate’s workforce is comprised these through an implementation plan. The In this agreement the supplier would create unplanned delay to this stage has allowed of Staff attached to the GHA from the eight core themes are outlined below: the backbone of the integrated electronic staff to be appropriately supported during Gibraltar Electrical Authority (GEA) and patient record (EPR) by developing their the bedding in of the Phase 1 EPR solution directly employed GHA staff. They cover the 1. Workforce Plan ( Succession Planning, core products and contracting previously and assisted in resolving all outstanding Clinical, Electrical, Mechanical Engineering Recruitment, H&S, Training, Specialisation, CPD, Apprentices & agreed third suppliers for the provision issues that have become apparent since going and Building Management Systems Graduates). of best of breed products for specialist live. It is planned that Phase 2 will result responsibilities of the GHA Estate. departments, e.g. critical care and maternity. in the implementation of Secondary Care 2. Resilience & Business Continuity Plan. The initial timeline for completion of the and Mental Health Patient Administration The management team is responsible full programme was three years with the Systems (PAS), the core Secondary Care for estates planning, engineering systems 3. Medical Devices Management Strategy. project split into three main phases: Phase 1, Clinical Documentation (i.e. General resilience & business continuity, lifecycle (MHRA Compliant). Phase 2 and Phase 3. Medical and Surgical Inpatient Wards and planning, space planning, utilities Secondary Care Outpatient Clinics) and four The introductory Phase 1 resulted in the non-core departmental systems: Maternity, introduction of Patient Master Index, Critical Care, Pharmacy and Theatres. Primary Care (Emis Web) and Accident and Emergency Department (Symphony) The introduction of the different systems in Electronic Health Records. During this Phase 2 will be modular and have a phased stage, the staff from these areas i.e. doctors, approach. The final stage, Phase 3 will nurses, AHPs and administrative staff were build on the secondary care core elements actively involved in the programme. In through the inclusion of Mental Health conjunction with the EPR Project / Deputy acute and community clinical systems and Project managers they led or assisted in an integrated electronic prescription and the configuration, development, training medicines administration (ePMA) system. and testing of the systems. This Phase was The decision will be made at this stage as successfully completed on the 24th June to which other noncore systems will be 2015. The outstanding item that required integrated into the final solution and this is continued development into Phase 2 has planned for early 2018. been the dispensing and reimbursement This journey has not been painless and as with solution for the community pharmacies. This all change programmes these are demanding is due to be completed in 2016. and difficult for most staff. However GHA Some of the benefits include; staff have been exceptional in the way they have managed the very complex transition in • there is no longer need for cards in such a short timeframe. Accident and Emergency Department • the ability to view previous attendances to these departments MANAGEMENT MANAGEMENT 100 101 4. Lifecycle Replacement Plan for completing their apprenticeship during the Capital Projects delivered during 2015 Solar Thermal System. Medical Devices, Plant & Infrastructure. first quarter of 2016. These programmes are • New Escalators at the entrance to St. of considerable value in preparing young Bernard’s Hospital. • Close Control and regulation of HVAC 5. Energy Conservation Plan. engineers for succession planning within the systems. Directorate. • Installation and Commissioning of the 6. Departmental Quality Plan. (ISO new 128 Slice CT Scanner. It is very gratifying and encouraging to report 9001:2008). that the department’s sustained commitment Capital Development Programme • Upgrading of the Hospital Signage. with respect to energy efficiency has 7. Audit System, (Internal & External). 2014 & 2015 been formally recognised following an The Directorate has been able to deliver • New Improved Surgical lighting at exhaustive energy use audit carried out by 8. Computer Aided Facilities Management on an ambitious capital development General Theatres. an independent energy assessment team. System (CAFM). programme made possible through the • New Surgical Microscope for Ophthalmic GHA’s Improvement & Development St. Bernard’s Hospital Staff Development Theatres. Funding allocation during both 2014 & St. Bernard’s Hospital has been awarded an During the period covered by this report, 2015. Many of these projects have been • New Large Porous Load Autoclave for the “ A” rating for Energy Efficiency. Technical staff attended a number of courses carried out by In-House staff and have been Central Sterilisation Services Unit. both locally and abroad reflecting the successfully delivered with the participation St. Bernard’s Hospital has been awarded an department’s continued programme of staff and collaboration of staff from many • New Emergency back-up generator “ A” rating for Environmental Impact. development. These included; departments including essential input from providing 100% resilience to Primary Care. Clinicians. The following list highlights some Ocean Views • Servicing Anaesthesia & Ventilation • New Dental clinic at the Primary Care of the major initiatives carried out during OceanViews Main Block C has been awarded Equipment. Centre. this reporting period. an “A” rating for Energy Efficiency. • Quality Assurance ISO 9001. • New Cardio Vascular ultrasound for the Ocean Views Main Block C has been Capital Projects delivered during 2014 Medical Investigations unit. • SR Hotline H-90 fluid warmers course. Installation of new public lift at St. Bernard’s awarded an “A” rating for Environmental Hospital. • Upgrade to St. Bernard’s Hospital Fire Impact . • Manual Handling Courses. Alarm System. • Redevelopment of the Endoscopy Suite Ocean Views Main Block D has been • Fire Training. to facilitate the Colon Cancer Screening • Commencement of works to new awarded an “B” rating for Energy Efficiency. programme. chemotherapy unit. • Risk assessment Workshops. Ocean Views Main Block D has been awarded an “B” rating for Environmental • Medical Gases Pipeline Systems - • Relocation of the Liquefied Oxygen • Design works for the expansion of Impact. Competent Persons (MGPS) Refresher- Tanks facility. Accident & Emergency Department. HTM 02 • Upgrade to St. Bernard’s Hospital Fire • New Domestic Services Administration Lifecycle Planning • Medical Gases Pipeline Systems - Damper Systems. offices. As can be appreciated from the report, the Authorised Persons (MGPS) Refresher- • Complete redevelopment & expansion of Directorate continues to support Healthcare HTM 02 the Community Mental Health Facility. Energy Efficiency Programme professionals with improvement projects Given that the GHA is a large consumer across all facilities. There is also considerable • Electrical Technicians conversion course. • New clinics and Boardroom at the of energy, the Directorate takes Energy work involved in planning and executing Efficiency very seriously. Our Technical the Health Authorities lifecycle replacement • Surgical Tables (T20+ &T30+) Service Primary Care Centre. Staff continue to be engaged with various plans. Training course • New Dermatology Suite at the Primary initiatives to monitor and improve building The Clinical Directorate’s workload is • CPD sessions on Quality Assurance, Care Centre. energy use across the GHA Estate. Some of directly linked to the number of assets in Medical Gases, Electrical Distribution and these initiatives include: • Upgrading of the UPS system at use and the age of the installed plant and HVAC Systems. Endoscopy. • Introduction of LED lighting in all new equipment. Both these factors are on the developments. increase and a sustained commitment to Apprentice Training Scheme. • Upgrading of the UPS system at the lifecycle planning is essential. The department is participating in Radiology Viewing Area. • Smart Metering. the development of apprentices. Four This is particularly important in the area mechanical apprentices have been attached • New Cardiac Alert system installed at the • Heat recovery from Air Conditioning of Medical devices, given the large asset to the GHA’s Mechanical Section as part of Primary Care Centre. systems. inventory on books and the critical nature of a 3 year training programme. They will be these devices. As the new hospital moves into • Assisting with the Design of the new MANAGEMENT MANAGEMENT 102 103 section is subject to very strict deadline Payments routines governed by the Government’s The Payments section’s main function remains Treasury Department that need to be reconciliation with Treasury and preparation adhered to in order to ensure the delivery of and processing of all documentation, in lines monthly payroll on 27th of every month. with accounting instructions, as required by the Treasury Department to settle any Account and Payments payments that need to be made by the GHA to external suppliers or clients. Accounts Physical revenue collection within the GHA This section also has to adhere to very strict and establishing patient entitlement to be able daily and monthly deadlines governed by to invoice costs where appropriate remains the Governments Treasury Department to the main role of the Accounts Department ensure the timely settlement of all GHA with patients accessing care at St Bernard’s payments. Hospital mainly via Accident and Emergency and the Ophthalmic Department. Operating with the Great Plains accounting software package the section keeps the main Accounts officers operate a 24/7 on call source of financial data for the organization service to assist in establishing health care to assist all devolved main budget holders/ entitlement. Senior Managers in analysing and controlling their elements of the GHA’s recurrent and Accounts officers as part of their role capital expenditure throughout the financial liaise closely with a large number of GHA year. Departments. Over 5,000 payments are prepared by the

its 12th year of operation, there is an increasing General Developments number of assets under management that The Department of Finance continues to are moving into the last phase of their strive to improve processes that will deliver recommended lifecycles. The department better budgetary control and financial works diligently to maximise the benefits of balance within operation of a devolved the allocated resources in order to mitigate budgetary system. clinical, operational as well as financial risks. Co-ordinating and improving the GHA’s estimate process is one of the main Finance 10.8 FINANCE & PROCUREMENT functions. This continues year on year. The total value of the accounts generated for the GHA, for the Financial Year ended 31st The revised MOD Secondary Health March 2015 was around £108.2m against Care agreement has now been operating an approved budget of around £101.6m. successfully since July 2014 delivering Detailed analysis of 2014/2015 expenditure benefits for both the MOD and the GHA. and comparative figures going back to Financial Year 2010/2011 follow the report. Payroll The Payroll section continues to provide Expenditure shows around £6.6m deficit all payroll support and runs the payroll over approved budget, but this needs to be operation of over 1500 monthly salaries considered in conjunction with budgeted comprising salaries of all GHA approved revenue for 14/15 performing positively by complement posts, contract posts, locum around £3.7m against an approved budget cover and around 260 salaries for Care of £49.9m. Agency nursing staff. Actual 14/15 revenue was around £53.6m.

MANAGEMENT Payroll processing, the primary role of the MANAGEMENT 104 105 team annually with the GHA’s annual budget Stores apportioned between around 60 internal The core roles of the stores team are; devolved expenditure accounts. • The upkeep and running of the main stores at St Bernard’s Hospital and other Procurement and Stores GHA external stores Procurement Procurement is responsible for the sourcing • the replenishment of stock items to all of any goods/items required by the GHA wards organisation. • liaison with Procurement section to A major role of Procurement is ensuring ensure minimum quantities of all stock value for money from suppliers in lines with items are available in the GHA 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. MANAGEMENT 106 107