It has been a busy a year in general for this Department when uniquely for long periods of time all geriatric and medical beds have been fully occupied. Many patients have been treated as outliers on surgical wards, frequently resulting in over 100 in-patients at any one time in the early months of this year. These patients are often elderly and have caused a burdensome increase in workload for medical and (more particularly) nursing staff, who have responded in a splendid fashion despite frequently nearing exhaustion. This situation resulted from a large increase in respiratory and other infections in January and February and partly from an increase in the number of elderly patients resident in St Bernard’s Hospital, who ideally should be looked after in the community and other areas for the elderly.

The outpatient workload has been fairly constant with around 2,000 patients per year within the department. The range of service provided is gradually increasing, with the provision of the Visiting Gastroenterologist reducing the need for potential referrals to the United Kingdom. Further areas will be looked at in the coming year, including the provision of a Visiting Consultant in Rheumatology and the development of closer links with both Spain and St Mary’s Hospital, London, in the field of renal (kidney) disease.

The KGVI wing, which was outlined in last year’s report is finally ready and will be opened during the middle of 1999. Patients will immediately appreciate an improvement in the general standard of Outpatient facilities, which we hope to improve even further with the development of a new Surgical Outpatients and Casualty wing located within the same building. For the first time medical secretaries will be a part of this integrated unit which will not only improve efficient working practices, but also enable scans and other investigations to Spain and the United Kingdom to be booked immediately, during the outpatient appointment.

It is also planned to link these extensive facilities directly to the EMIS computerised general practise system enabling direct booking of appointments, and communication of medical information in both directions quickly and efficiently. Medical voice recognition systems, which are already available will be introduced to improve the efficiency of this process.

It is recognised by all that an integrated system of elderly care needs to be developed in the coming year. This has been especially highlighted by this year’s pressure on the acute Hospital beds. Inevitably the geriatric pressure in the acute hospital will diminish and with only acutely sick elderly patients being dealt with on the acute Medical Wards and all others cared for in a graded community care system. It is envisaged that this will be headed by the appointment of a full time Geriatrician working largely within the community.

There has been considerable progress during the last year. Most of these improvements have yet to bear fruit but the Outpatient Medical Unit with all its innovations will be the highlight of the coming year for our Department. Considerable steps will be taken to facilitate improved care for the elderly resulting in immediate advantages for the acute sector generally.

The Consultant Paediatrician attends all deliveries where the infant is considered to be at risk. All newborn babies are examined by a doctor before they are discharged home. Sick babies are observed and treated in the baby unit. If specialised treatment that is not available in Gibraltar is required, babies are transferred by ambulance, with a nurse and doctor escort, to the Hospital Materno Infantil in Malaga. In some cases the mother is sent to Malaga for delivery of a baby who is considered to be at risk because of prematurity or suspected congenital abnormality.

Perinatal mortality has improved remarkably over the years and figures are shown in the appendix. They show that the risk to a newborn baby at delivery was comparable with the UK in the 1960s, but failed to improve in the 70s, because of a lack of equipment and trained staff. Over the 1980s, the mortality rate improved and in the 90s, is now again comparable with the UK average. This is very creditable, considering that the St Bernard’s Maternity Unit, because of the limited number of births, cannot aspire to give the intensive neonatal care service that is accessible to most units in the UK.

Landmarks in service improvement:

1980: First full time Paediatrician appointed

1988 First Special Care Baby Unit (SCBU) trained midwife appointed

1996: Arrangements made to transfer critically ill new-borns to the Hospital Materno Infantil, Malaga

Rainbow Ward is a 16 bedded Children’s Ward which accommodates medical and surgical paediatric patients. Every effort is made to make the ward child- (and parent-) friendly. The staff participate in weekly consultant outpatient clinics and ward follow-up clinics (twice weekly), including a multidisciplinary Diabetic Clinic (held every three months outside the hospital, so that parents, children and professionals can meet in a non-clinical setting) and a clinic for children with severe respiratory problems. We hope to start an Asthma clinic in the coming year. Direct advice and help is freely available for the parents of children with severe or chronic diseases, and our ambition is to extend this to an outreach service into the homes of such children. Internal rotation for night duty is now established, so that at least one of the nurses on duty at all times is qualified.

The Infant Welfare Clinic (run by the Health Visitor) and the School Problems Clinic (run by the School Nurse) are held in the Health Centre. The Health Visitor, assisted by two enrolled nurses, usually visits all newborn babies after their discharge from the Maternity Ward, and holds three well-baby clinics each week in the Health Centre. She also conducts hearing tests on all 7-month-olds, and assesses the development of all 3-year-olds either in the Health Centre or in Government Nurseries. She holds combined Audiology clinics with the Senior Speech Therapist, to follow up potential problems encountered in the 7 month hearing check, as well as referrals from Speech Therapy and Paediatric clinics. A variable number of Parentcraft classes are carried out by the Health Visitor in the evenings.

Two Community clinics are held weekly in the Health Centre by the Consultant Paediatrician, on Tuesday and Friday mornings. On Tuesday mornings he is assisted by a general practitioner. These clinics ensure that all babies are seen by a doctor at the ages of 6-8 weeks, 7 months, 15 months and 2 years. The Paediatrician conducts a Special clinic on Monday afternoons where babies who require special follow-up and children with school-related problems are seen. Once a month, there is a combined clinic with the Educational Psychologist. The Paediatrician visits St Martin’s Special School every week, and chairs the Assessment Panel for children with learning disability

There has been much speculation that the incidence of cancer is high in Gibraltar. A definitive answer to the question must await the collection of statistics by the proposed Cancer Registry. However, the incidence of childhood cancer does not appear to be unduly high. In the 19 years from 1980 to 1998 inclusive, there wee 13 cases of malignant disease in children between the ages of 0 and 14 years. Since there were 7317 births in this time, this gives an incidence of 93.5 cancers per million patient years, which compares favourably with figures from Great Britain (101.6) and most other countries.

The fact that 9 of these 13 children survived and are in good health illustrates the improving outlook for children with cancer, most forms of which are now treatable and indeed curable in most cases.