Type of Review: Project Completion Review
Project Title:
Essential Human Resources for Health and Social Services: St Helena
and Tristan da Cunha (HealthLink3)
Date started: 1 October 2008
Output Description
Outputs substantially exceeded expectation
Outputs moderately exceeded expectation
Outputs met expectation
Outputs moderately did not meet expectation
Outputs substantially did not meet expectation
Date review undertaken: February 2012
Scale
A++
A+
A
B
C
Outcome Description
Outcome substantially exceeded expectation
Outcome moderately exceeded expectation
Outcome met expectation
Outcome moderately did not meet expectation
Outcome substantially did not meet
expectation
Introduction and Context
What support did the UK provide?
1. DFID provided £4m financial support for the 3 ½ year HealthLink3 project of which £577,500 was
allocated to cover costs of recruitment and deployment of essential human resources on Tristan da
Cunha and the remainder was allocated to St Helena.
St Helena’s own contribution to the project was a total of £721,000 or £206,000 per year to cover the
cost of travel of recruited personnel and the cost of the nurses’ salaries/support link. Total budget
available for the St Helena part of the project therefore was £4,142,980 of which 83% was provided
by the UK.
The HealthLink3 project commenced 1 October 2008 and ended 31 March 2012.
What were the expected results?
2. The project aimed to contribute to improved quality of health and social services and care
within an efficient and sustainable system through the provision of high quality appropriate
skilled health and social services staff and required support system.
The planned outputs for the project were:
Output 1 Appropriate long term health and social service personnel provided
Output 2 Selected short-term consultants and remote advice and/or telemedicine for specialist care
provided.
Output 3 Human resource capacity of PHSSD and SHG Personnel Dept to recruit, manage and retain key
health personnel developed.
Output 4 Improved on-island capacity in St Helena and Tristan to deliver essential services
Output 5 Staff on island benefited from ongoing professional development through capacity building and a
skills transfer process
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What was the context in which UK support was provided?
3. Healthlink 3 (HL3) is the last in a series of technical assistance projects implemented by Northern
Ireland Co-operation Overseas (NICO) in support of the St Helena (SHG) Health and Social
Welfare Directorate and Tristan da Cunha Island Administration. The cooperation with NI-CO
started in 1991. While DFID held the contract for the earlier HealthLink projects, for the HL3 project
NI-CO was contracted directly by and responsible to the Government of St Helena (SHG).
4. The Healthlink 3 project supports and feeds into a larger programme of work under the banner of
the St Helena Health and Social Services Development Strategy “Focusing on the Future” which
ran from 2008 to 2011 and was subsequently integrated into the Directorate’s strategic plan 20112014 and 2012-2015. The project complements the DFID supported Health Strategy project.
5. The overarching rationale for the project is to ensure that high quality essential health and social
services are available on St Helena and Tristan da Cunha (TdC), and that these services are
provided in an appropriate cost-effective manner, as far as possible building up on-island capacity.
6. Cost-effective provision of high quality secondary and specialist services is a recognised problem
for small-island communities globally. Human resource capacity on island is not sufficient to
provide the minimum package of social and health services and care required for the island
community. Furthermore, it is not possible to provide a wide range of secondary health services on
island because of insufficient workload leading to low cost-efficiency and loss of skills of the staff.
The cost of overseas referrals is related to skills mixed and diagnostic and treatment options
available on/off island. Costs of overseas medical referrals are regularly monitored1,2. The cost for
referrals tends to rise sharply as the population becomes older. Therefore there is a justification to
ensure an appropriate skill mix of doctors and health/social services staff on island with adequate
distant support links and a well-planned visiting specialist programme; rationalising the timing,
frequency and skills required of visiting specialists.
7. The St Helena health strategic plan emphasises the importance of establishing and where
necessary expanding an effective prevention programme and improving the management of long
term conditions within a social care model of service provision. More efficient use of specialist
expertise through use of remote specialist advice and the establishment of telemedicine links will
play another important role in addressing some of the cost pressures.
8. An important component of the project is capacity building and the transfer of skills to reduce the
need for external support for service provision and to enable SHG to take on the recruitment and
contracting of health and social services staff seeking expert inputs and support as required. It is
however envisaged that Tristan da Cunha (TdC) will continue to require external support to identify
and recruit medical and dental staff beyond the project.
9. The project is fully consistent and supports the SHG and the Tristan da Cunha Sustainable
Development Plans, the SHG Public Services Modernisation Programme and the new UK White
Paper on the Overseas Territories (2012). This is underpinned by the UN Charter: “to promote to
the utmost, within the system of international peace and security established by the present
Charter, the well-being of the inhabitants of these territories”.
1
Cost-effective Delivery of Specialist Medical Services to the St. Helena Population: Review of Options, Lasse Nielson 2006
2
Public Health and Social Services: Overseas Medical Referrals - Value for Money Report, St Helena Audit
Service, 2008
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Section A: Detailed Output Scoring
Output 1: Appropriate long term health and social service personnel provided
Output 1: final score and performance description: A - Output met expectation
Final results:
The timely provision of appropriate well qualified long-term health and social services personnel for St
Helena and TdC was one of the key outputs of the project which has been fully achieved. Both islands
benefited from the extensive expertise of NICO and their wide networks which facilitated timely
recruitment sometime within very tight deadlines. All in all the project assisted with the deployment of
25 long-term staff and 25 locum officers.
St Helena:
St Helena has a population of 4,000 people. Essential clinical areas were covered by a full complement
of 4 doctors for 96% of the time and 1 dentist with adequate locum cover during planned absences with
the exception of a few weeks in 2009 and 2 weeks in 2010 during which only 3 doctors were on island.
Similarly during unplanned absences when one of the medical officers had to accompany a patient to
Cape Town (2 times in 2011/1 time in 2012) 3 doctors with adequate skill mixed remained on island.
Difficulties in recruitment of long-term medical officers resulted in less than ideal reliance on locums at
times.
Apart from ensuring a full complement of 4 doctors and 1 dentist on island, the project also supported
the recruitment of 11 non-medical long-term staff including nurses, social worker, physiotherapist and
laboratory personnel.
Based on a careful analysis the decision was made to expand the total complement of doctors to 6
doctors to broaden skills mix of the medical team and reduce reliance on locum cover. This is expected
to result in improved quality and range of care available on island and reduce referrals. The fifth doctor
will have main responsibility to improve primary care (especially prevention services and improved
management of non-communicable diseases), while the 6th doctor will be a specialist
gynaecologist/obstetrician. While the recruitment process for 2 additional medical officers commenced
during the HL3 project, the fifth doctor commenced work on island in April 2012 and the sixth doctor in
August 2012.
Tristan da Cunha (TdC):
TdC has a population of just 262 people. Essential clinical areas are covered by a medical officer with
locum cover during leave periods. Difficulties in recruiting a resident long term medical officer resulted
in heavy reliance on short-term locum cover. The ToRs and job title have been amended in order to
improve chances of attracting suitable candidates to the post. Currently a good numbers of suitably
qualified doctors are on register but the isolated nature of the post is the main obstacle to attracting
suitable candidates for a longer term posting and/or establishing a rota system. While clinical areas
were adequately covered by the (locum) medical officers, not all tasks/responsibilities as reflected in
the Job Profile have been addressed, including the development, costing and implementation of a
medical operational plan with realistic milestones and targets although some progress has recently
been made by one of the locums. The frequent changes impact on continuity of care and may affect
quality of care provided. The possibility of contracting an agency to provide oversight to ensure
continuity of high quality care and reporting against agreed standards and targets is being explored.
For St Helena and Tristan da Cunha: All long term and dental recruits and majority of medium term
officer having patient contact were fully screened according to UK NHS guidance. Non clinical staff all
completed SHG medical questionnaire and had screening according to SHG requirements. Not all
medical officers recruited hold UK / EU qualifications but all have relevant qualifications from medical
schools on WHO Avincenna Directory. UK / EU qualifications will not always be possible when
undertaking global recruitment.
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PCR HL3 2012
Key lessons learnt:
1. Doctors are continuing to specialise earlier in their careers and the types of multi skilled doctors
required for St Helena and TdC are becoming increasingly difficult to find. This situation is
unlikely to change and therefore a new way of approaching recruitment for the Islands will be
required. A flexible approach will be essential and applications from beyond the traditional
sources of the UK and South Africa will be necessary. The skills mix required on both Islands will
need to be proactively reviewed on a regular basis and Terms of Reference for new posts will
need to take account not only of what is required, but also of what is available and possible.
Allowing sufficient time for the recruitment process is crucial. If potential vacancies are identified
well in advance, with at least 6-8 month notice, this will provide the best possible opportunity for
successfully filling the post with a high quality candidate and of ensuring continuity of service.
However, on Tristan da Cunha the biggest obstacle to successful recruitment of a long-term
medical officer with required skills mix is its isolation.
2. The importance to remain vigilant to ensure all necessary steps in the recruitment process are
completed and documented cannot be overstated. A step-wise recruitment/assessment plan has
been prepared and is followed which includes appropriate vetting, completion of occupation health
assessment, medical check-up and obtaining medical indemnity cover. Contract amendments
have been made – making the post holder responsible - to provide an additional safety net to
ensure all required documentation/certificates are submitted prior to commencing post.
3. All prospective long-term employees have had a full NHS occupation health screening check in
the UK which is an expensive and sometimes logistically challenging process requiring travel to
the UK. An independent GP in the region could possibly be used to carry out the pre-employment
check utilising approved check-forms. This would possibly reduce travel costs and costs per check
from £300 to £100.
Impact Weighting: 15%
Revised since last Annual Review? NO
Risk: Medium
Revised since last Annual Review? NO
Output 2: Selected short-term consultants and remote advice and/or telemedicine for specialist care
provided.
Output 2: final score and performance description: B - Output moderately did not meet
expectation
Final results:
Taking a flexible and responsive-to-local needs approach the project has been able to support St
Helena and TdC with the provision of short-term consultant inputs while TdC and St Helena have both
formalised various links for remote advice. In total 20 short-term experts were deployed through the
project with many making multiple visits over the duration of the project; 24 visits were delivered on St
Helena and 11 on Tristan. St Helena with a more extensive annual plan of visiting specialist and distant
support requirements achieved 80% of annual targets. Plans for TdC were amended to take account of
support needs of nursing staff and the vacancy of long-term medical officer post. Link arrangements
between St Helena and NHS Trust in Devon/UK are being finalised. The recent NHS reforms and busy
work schedule of all involved caused additional delays in formalising the link. Although St Helena has
benefited from technical support and distant advice during the past year, the link is not yet fully up and
running and the cost-effectiveness of the link has yet to be determined. Agreement on appropriate
communication and coordination channels will be important. Detailed multi-year work plans with clear
time frame for required specialist inputs on island are expected to facilitate timely sourcing of required
expertise thereby reducing time and transaction costs for St Helena.
St Helena:
Annual plans for recruitment/deployment of short-term personal prepared and regular updated; 80% of
short-term expertise obtained as per annual plan (calculated by looking at number of TA days delivered
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PCR HL3 2012
against number of TA days planned). Visits of gynaecologist and ophthalmologist were delayed in FY
2010/11 and FY 2011/12 respectively, but took place in subsequent years. The visit of an internal
medicine specialist did not take place as planned (postponement due to family circumstances and
subsequent cancelled) although a GP visit organised through the NHS link provided some of the
required TA inputs. The project supported specialist visits in a wide range of clinical and non-clinical
specialisms.
Regular informal distant support from SA specialists as/when required with regular distant support
arrangements formalised for 1) radiology (review of X-rays in South Africa), 2) mental health from SA
based psychiatrist and UK based psychologist in between visits, 3) eye care from UK based
optometrist in between visits esp. with respect to retinal photo’s, 4) laboratory from UK based
biomedical scientist and 5) nurse education with UK based nurse trainer in between visits.
Delays in formalising and finalising the NHS link arrangements with Devon UK resulted in the link not
being fully established and consequently the NHS link has yet to show it will provide value for money.
One of the key objectives of the NHS link is to facilitate sourcing of specialists and required distant
support thereby improving quality of care and reducing transaction costs. Over the past year technical
support and specific requested inputs have been provided through the NHS link. A detailed workplan
for the expected link inputs/outputs has been prepared but further discussions are required to agree on
timing of specific inputs. It will be important to appoint a link co-ordinator with clear ToRs in Devon as
well as on St Helena to ensure smooth implementation of the workplan. The workplan will be reviewed
and updated as required on a quarterly basis.
Annual referral patterns and options for improving cost-effectiveness of secondary care provision on
and off island were reviewed with assistance of a health economist (desk-based TA) to identify options
to reduce costs of referrals and improve health services and care on island. Recommendations
included formalising arrangements with referral hospitals in South Africa (and associated remote
advice) and a review of insurance options, including stop-loss insurance for overseas referrals.
Follow-up of implementation of recommendations provided by visiting experts/specialist has improved
over time through involvement of Health and Social Welfare Directorate (HSWD) Clinical Governance
Committee, but needs further strengthening. All visiting experts are required as per their ToRs to
discuss observations and recommendations prior to departure - although this is not always adhered to and to include a review of status of implementation of agreed actions/recommendation from previous
visits in relevant speciality area in their end-of-contract report.
Tristan da Cunha:
Timely provision of appropriate well qualified short-term consultants and achievement of targets set
although some delays in the sourcing of support to increase skills set of nursing on island; recruitment
of a long-term qualified nurse in follow-up to identified needs (1yr contract) who commenced work early
2012. Visiting experts included 1) annual visits of dental team, 2) every other year visit of optometrist,
and visits of 3) medical architect (2011) and 4) nurse trainer (2010).
Formal arrangements for distant support and referrals have been set-up between TdC and Grote
Schuur University Hospital in Cape Town which is expected to reduce referral costs. For mental health
care a support link has been set-up with a South Africa based psychiatrist while a link with a Dental
School is being explored. St Helena has provided limited distant support in elderly care and has offered
further support if/as required. Remote support requirements in environmental health and public health
will be reviewed once there is further clarity if and how the long-term medical officer’s post will be filled;
TdC is currently relying on short-term locum cover for this post.
Key lessons learnt:
1. The establishment of a link with an UK NHS Trust has been time consuming and requires
careful nurturing to ensure its full potential can be reached.
Impact Weighting: 15%
Revised since last Annual Review? NO
Risk: Medium
Revised since last Annual Review? NO
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PCR HL3 2012
Output 3: Human resource capacity of PHSSD and SHG Personnel Dept to recruit, manage and retain key
health personnel developed.
Output 3: final score and performance description: A - Output met expectation
Final results:
Enhancing capacity on St Helena and TdC to independently recruit, contract and manage international
health and medical staff was another key objective of the project which has been achieved after an
initial slow start. By the end of the project SHG has demonstrated that it is able to manage recruitment
and contracting of required long-term and short-term health personnel. On-going technical support will
be sought as required for the recruitment of long-term medical staff. The NHS-link is expected to
facilitate the recruitment of short-term specialists and remote support links as well as being a source for
CPD for nursing and medical staff. While all visiting specialists/consultants are covered by an
individual malpractice cover a decision is yet to be made by SHG whether to take out malpractice
insurance for the health department.
For TdC an arrangement with NI-CO for on-going support for the recruitment of short- and long-term
health personnel has been agreed. All staff will be directly contracted and managed by TdC Island
Government.
TdC and St Helena have both prepared detailed lists of TC requirements for the next 3 years. Funding
has been secured for TdC for 2012-2015 within the approved Business Case for Capacity Building
2012-2015 while for St Helena the TC-health budget allocation has been agreed for 2012/13 and
indicative budgets have been discussed for 2013/14 and 2014/15.
St Helena:
Progress was initially restricted due to staffing constrains in both HR and H&SW Directorates. During
the last project year final preparations were made to ensure that SHG has the capacity to undertake
the medical and non-medical recruitment once the HL3 project is completed. This included obtaining
an extra member of staff for the SHG UK Representative (initially paid for by the project) and moving
forward with upgrading a post within the DHSW to a more senior level. During the annual NI-CO project
management visit earlier this year staff from HRD, HSWD and NI-CO spent time discussing the key
requirements that are unique to medical recruitment. The recruitment manual and checklists were
updated by NI-CO and submitted to SHG together with a number of additional annexes. This will need
to be reviewed and amended by SHG once the split in tasks between HSWD, HRD and the office of
the SHG UK Rep have been agreed. It is however anticipated that the SHG will seek support from a
recruitment agency for the recruitment of medical officers and specialists also beyond the end of the
project for posts that cannot be sourced through the NHS link. While NI-CO would be available to
provide on-going support the SHG has also been exploring other avenues. By the end of the project all
internationally recruited staff had SHG contracts and two long-term posts (pharmacist and dentist) had
been filled successfully by SHG without inputs from NICO.
DHSW developed its Human Resource (HR) Development plan which is regularly updated by SHG HR
department with inputs from DHSW. This plan provides an overview of staffing levels, vacancies and
specific training requests. All job profiles have been updated as part of a pay and grading review
(completed 2009/2010). A functional analysis planned under the Public Sector Modernisation Project
(PSMP) has not been completed and is now scheduled for later this year to review operational
management of various sections and identify optimal staffing levels for health and social services,
including elderly care, taking into account hospital, sheltered accommodation and Community Care
Centre redevelopment plans and any current / future gaps in human resources and skills set
requirements.
A job satisfaction survey conducted by PSMP revealed low job satisfaction amongst health/education
staff which could possibly relate to relative high staff turn-over and high absenteeism especially
amongst hospital staff. Further work is planned by PSMP to assess underlying causes. Some initial
work to improve staff morale and team working in the hospital was initiated by the visiting clinical nurse
manager in 2011 (paid for by the strategy project) while further work is planned later this year.
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PCR HL3 2012
The project supported the development of annual plans for international recruitment and earlier this
year a 3 year plan for international recruitment of long term consultants/experts was prepared, while
short-term posts are expected to be sourced through the NHS link unless visiting specialists have
agreed and confirmed a subsequent visit. DHSW submitted a detailed list of external expert/
consultant inputs and related budget requirements for April 2012 - March 2015 to SHG Chief Secretary
and Finance Department to ensure high quality essential health and social services will be available for
the population and funds secured for such beyond the HL3 project. The list was discussed during the
DFID budget aid review earlier this year and accepted with minor modification. The Health-TC budget
will be managed by the DHSW with oversight from the SHG Chief Secretary.
New performance management forms have been introduced in 2010 by SHG for mid-year and endyear performance reviews. These forms have been successfully used for annual performance review of
staff contracted under the project. Training needs for current and future jobs are discussed during
performance review meetings. Key training requirements for DHSW are subsequently included in the
aforementioned HR development plan.
Project funds have been used for the payment of indemnity cover for individual medical resident
officers and locum cover while visiting specialist are expected to have their own indemnity cover with
additional expenses paid by the project. NI-CO was tasked to research options and costs for the
provision of an extended medical malpractice insurance for the health department considering current
and future risks of a claim being lodged against SHG and taking into account the increase in visitors
with imminent air access. The draft paper was discussed with Crown Counsel earlier this year and
submitted to the Chief Secretary for further action.
Tristan da Cunha:
The project supported the development of annual plans for international recruitment of short-and longterm staff and experts/consultants. Earlier this year a 3 year plan for on-going requirement of
international recruitment of long term consultants/experts was prepared in close consultation with TdC
Island Government and integrated within the Tristan da Cunha Business case for Capacity Building
2012-2015. The Business Case was approved thereby securing funding for required on-going
expert/consultant inputs beyond the HL3 project.
TdC island Government will take over the contracting and management of Long-Term and Short-Term
personnel but on-going assistance of a recruitment agency will be needed to source these experts
unless visiting experts/consultants agreed and confirmed a subsequent visit. Both the optometrist and
dental technician have been providing services on island for many years. The dental team and
optometrist already agreed to make another return visit while also the psychiatrist - currently providing
distant support - has agreed to visit in Sep/Oct 2012. Arrangements have been discussed and agreed
with NI-CO for support beyond the project end date.
Individual performance management of all nursing staff was conducted by visiting nurse teacher
(2010). The qualified nurse recently recruited is expected to introduce a performance culture with
regular performance management of all health staff.
Impact Weighting: 30%
Revised since last Annual Review? NO
Risk: Medium
Revised since last Annual Review? NO
Output 4: Improved on-island capacity in St Helena and Tristan to deliver essential services
Output 4: final score and performance description: B - Output moderately did not meet
expectation
Final results:
The objective of this output was to improve knowledge and skills of on island health and social services
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PCR HL3 2012
staff to enable improved service provision. The project provided responsive and need-based support to
enhance on island capacity. Milestones and targets originally set were revised to respond to emerging
needs. Difficulties in recruiting an UK diabetic nurse for a 3-6 month posting delayed the planned skills
improvement of the diabetic and cardiac nurse on StH, which is now scheduled to take place later in
2012.
On TdC the skills and training needs assessment by the visiting nurse trainer highlighted the need for
long-term input of a qualified nurse/trainer to improve the skills set of health staff on island and ensure
adequate support for the doctor during medical emergencies, including operations. A Tristanian long
term qualified nurse commenced work January 2012.
St Helena:
On island capacity has substantially improved over the past few years with nurses taking a pro-active
role in delivering high quality essential services in the hospital and in the community during nurse-led
clinics and alongside medical officers. The project supported the development of protocols/guidelines,
patient self-directives and training of nursing staff. The visiting clinical nurse manager supported
improvements in clinical governance and hospital management. The UK community nurse officer
during her 2 year tenure on island provided substantial inputs to improve primary care service provision
by the community nursing team, including introduction of check-lists, recall for routine screening and
monitoring of service provision using EHMIS. Two staff received additional training in triaging by the
visiting GP through the NHS-link.
The high prevalence of Non-Communicable Diseases (NCDs) is a concern on both St Helena and
Tristan da Cunha and enhanced skills of nurses to provide care and support to patients during routine
check-ups seen as important to improve management and early detection of complications. The
capacity of St Helena diabetic and cardiac nurses to routinely follow-up hypertensive and diabetic
patients has been further strengthened and they are now able to provide repeat prescriptions. In 2011
83% of routine screening of hypertensive patients was done by cardiac nurse and 56% of diabetics by
diabetic nurse. The first well above target, while the latter is slightly below target which could be
explained to fact that the diabetic nurse had to fill in the vacant community nursing officer post. This
post is now filled by a substantive post holder. St Helena is considering training another nurse in
diabetic care.
The project training programme as indicated under targets/milestones has not taken place as planned.
An island visit by an UK diabetic nurse through the NHS link to provide on-the-job training on diabetic
care including training in wound/foot care and patient self-management was postponed till later in 2012
due to difficulties in identifying a suitable candidate. The optometrist during her annual visits provided
training to 2 staff – ophthalmic assistants - and both are now competent in visual field determination
and retinal photography. One of the selected staff has the potential to be trained in providing simple
eye care with additional on-line training, but has indicated not to be interested. DHSW need to explore
whether any other staff member would be interested and able to be trained to provide simple eye care
throughout the year. One of the qualified nurses received additional training in occupational health with
further on-island support from a UK trained occupational health therapist through VSO (Volunteer
Services Overseas). Although she is now able to provide rehabilitation support in various areas further
on island training and support needs have been identified.
Substantive improvements have been reported related to appropriate triaging of patients during out-ofoffice hours and in preparation of specialists visits. Visiting specialists report that most patients seen
are appropriate triaged with lists of patients shared prior to the visit to enable efficient planning of the
visit and timely ordering and transport of required supplies. The lack of a formal triaging system for the
optometrist visits resulting in often long working hours during visits. Target of reduced duration of visits
by clinical specialist of 100 days/year not achieved, but possibly not realistic considering the annual
lengthy visit by the optometrist responsible for 60-70% of the annual target. It is however envisaged
that reliance on a visiting gynaecologist/ obstetrician will reduce once the 6th medical officer (i.e. a
gynaecologists/obstetrician) is in post.
Tristan da Cunha:
A skills and training needs assessment was completed in 2010 by the visiting nurse trainer. All nursing
staff received basic training from the visiting nurse trainer and on-going training from the resident and
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PCR HL3 2012
locum medical officer. The reliance on locum cover over the past year negatively impacted on the
continuity of the required training and skills transfer process. The low level of competency and skills
currently available meant that specialist training was not considered appropriate at this time and as
such the targets set for Tristan were not achieved and consequently the establishment of nurse led
NCD clinics not an option. However, on TdC with only a small population the medical officer would be
able to regularly check-up and manage all NCD patients.
On island capacity to provide simple dental care has improved through training and on-the-job
coaching of the dental nurse during annual dental visits. The dental nurse is able to provide high quality
routine dental work and cleaning (see also under output 5).
The dental nurse successfully implements a triaging system for the annual visits of the dental team.
There is formal triaging system in place for bi-annual visits of the optometrist, but as time on island is 23 weeks - depending on the shipping schedule – this does not pose a problem.
Impact Weighting: 30%
Revised since last Annual Review? NO
Risk: Medium
Revised since last Annual Review? NO
Output 5: Staff on island benefited from ongoing professional development through capacity building
and a skills transfer process
Output 5: final score and performance description: A - Output met expectation
Final results:
This output is linked to output 4 in that it focused on training and development of local staff in order to
build on island capacity to deliver essential services. Achievements under this output have met
expected targets. Staff capacity on St Helena has considerably been enhanced through training and
skills transfer using various means. High quality guidelines and procedures have been put in place and
staff trained in its use. Regular performance reviews, taking account of findings of routine and ad-hoc
audits and routine monitoring/supervision provide a sound basis to identify areas requiring further
strengthening to ensure health and safety standards are adhered and service provision on island is of
high standards.
On island capacity of nursing staff on TdC is limited but is expected to increase over the coming years
through a well-planned training programme, on-the-job coaching and leading by example by the
qualified nurse who commenced work early 2012.
St Helena:
Continual Professional Development (CPD) activities as well as identified training needs of DHSW staff
are summarised in annual training plans and in-house expertise as well as expertise of visiting
consultants/experts are used to provide the required training. ToRs for all contract staff include
role/responsibilities related to training and on-the-job coaching and all long-and short term staff
delivered training while on island. Routine and ad-hoc clinical audits provide additional insight in areas
requiring attention and training. Training needs and career development interests are discussed during
annual performance review meetings. Nurses are now given protected time to attend training days and
this is registered on the duty rota. During the past year a few training sessions were provided by
VC/telcon through the NHS link and this venue provides opportunities for advanced training in selected
topics for medical and health staff through VC as well as through a tailored made training programme
in the UK. Additional training on the Electronic Patient Monitoring System was provided during island
visit as well as by VC. All staffs are now able to input data on the EHMIS, while some have acquired
skills for (limited) analysis.
Over the past years many guidelines and protocols have been updated and/or newly developed aiming
compliance with UK standards whenever feasible/appropriate while their adherence is checked during
audits and spot-checks. The project supported an extended visits of a clinical nurse manager and
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PCR HL3 2012
annual visits of a nurse trainer. Both also provide on-going remote support. A further short-term visit
from the clinical nurse manager is planned in June’12.
The School of Nursing has been a particular success story of the project even though the project was
unable to assist with identifying and setting up link arrangements after Queen’s University Belfast 10
year arrangement ended in 2010. The nursing curriculum was revised to conform with the European
credit transfer system framework, providing the students with the opportunity to be awarded an EU
level 6 diploma credit for the 3 year nursing education on island and thus accommodating a more
broader and flexible route of entry into Higher Education in the UK. The nursing school moved to new
premises in 2010/11 providing a much better learning environment for the students while arrangements
for and support during placements have substantially improved over the past few years with inputs
from the visiting nurse trainer; 83% of qualified nurses have attended the mentorship course while an
update mentorship day is planned for April/May 2012 to ensure that all qualified nurses are aware of
their role and the importance of being a supportive mentor to students during their clinical experience.
The project supported the procurement of additional training materials and tools for the nursing school.
On-going external support is required for the resident nurse teacher to ensure that the current high
standards are maintained and for regular review of the curriculum and quality of teaching. Moreover the
establishment of an Examination Board has been recommended with internal and external quality
assurance frameworks.
The St Helena nurse teacher completed her training and commenced work on island in June 2009.
Targets for number of students completing the nurse education on island were achieved (6 nurses
graduated from St Helena School of Nursing). One student successfully completed his diploma in
Mental Health Nursing in the UK and commenced work as mental health nurse early 2012 alongside
the UK contracted mental health nurse who will provide a mentoring role during the first year. StH
Health Promotion co-ordinator successfully completed her training placement in the UK (through NHS
link). There are currently 10 students enrolled in the nurse training on island (5 first year, 2 second year
and 3 third year). Whilst this is an improvement on previous numbers in recent years, it gives little
margin for ensuring sufficient capacity building for future nursing service and reduced reliance on
externally recruited qualified nurses. Consideration should therefore be given to increasing the yearly
intake of first year students to 6 to ensure sufficient numbers should some decide to abandon and not
complete the programme. The latter has unfortunately occurred on a few occasions when better paid
job opportunities present themselves on StH or abroad.
Tristan da Cunha:
None of the nursing staff on TdC have had any formal training. Regular training sessions and on-thejob coaching sessions were provided by the resident and locum medical officers. The performance
assessment conducted by the visiting nurse teacher (2010) identified individual training needs and
interests and basic training was initiated during her short tenure on island. This will be taken forward
and a longer-term HR development plan prepared by the qualified nurse who commenced work on
island early 2012. Remote support will be available from the UK based nurse trainer.
The dental nurse and dental nurse assistant received training from the dental team during their annual
visits. The dental nurse is able to provide high quality dental care, including preventive services and
simple fillings throughout the year. Additional training needs to expand the skills set of the dental nurse
has been identified which will however require training and travel off island. For the time being annual
visits from the dental team will still be required to complement the services that can be provided by the
dental nurse.
Impact Weighting: 10%
Revised since last Annual Review? NO
Risk: Medium
Revised since last Annual Review? NO
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Section B: Results and Value for Money.
1. Achievement and Results
1.1 Has the logframe been changed since the last review? No
Substantial changes were made in the logframe during its first year and the HL3 logframe was
nested underneath the strategy project logframe to ensure maximal complementarity of the 2 DFID
funded projects. However, overall project goal and purpose did not change.
1.2 Final Output score and description: A - Output met expectation
A flexible and needs-based approach was followed allowing flexibility in the mobilisation of required
inputs to deliver the expected outputs. The project facilitated continuity and further expansion of
range and quality of service provision on island with distant support links in key areas. On St
Helena monitoring of patient care and evidence-based planning were further enhanced through
improvements in Electronic Patient Management Information System and staff training in its use.
The project can overall be considered a success even though not all objectives were fully
achieved.
1.3 Direct feedback from beneficiaries
Direct feedback was obtained from various partners and stakeholders during island visits. NICO
presented an overview of achievements against objectives to the Health and Social Welfare
Committee and Legislative Council during the island visit early 2012. This provided the
opportunity to obtain direct feedback from political leaders.
All acknowledged the substantial financial and technical support provided by the project and
specifically the support provided by NICO. Although some concerns were expressed related to
the imminent end of the project and whether StH would be able to timely recruit high quality
essential health staff, the systems set up to ensure on-going timely recruitment provided sufficient
assurances.
DHSW introduced the use of a patient satisfaction questionnaire late last year to obtain routine
feedback from patients on services provided in the hospital. The questionnaire is provided upon
admission with a request to complete upon discharge. Routine data were therefore only collected
for hospital admissions and only towards the end of the HL3 project and are not included in the
report.
1.4 Overall Outcome score and description: A - Outcome met expectation
The project supported the recruitment of high quality appropriate skilled health and social services
staff and the establishment of remote support links.
On St Helena the gradual handover of contracting, management and recruitment supported with
simple check-lists and a recruitment manual will ensure that this will be sustained beyond the
project end date. For TdC arrangement have been agreed for on-going support from NI-CO at
request. Both St Helena and Tristan da Cunha have detailed recruitment plans in place and have
secured funding for contracting international experts/consultants beyond the end of the project.
The project has therefore achieved outcome level expectations even though not all output and
outcome level targets were fully achieved.
1.5 Impact and Sustainability
The project significantly contributed to improving health service provision and range and quality of
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health care available on both St Helena and Tristan da Cunha and thus towards improving health
outcomes.
On St Helena capacity was built and systems established to sustain the gains made by the
project. The planned recruitment of a high level HR staff within DHSW and additional staff input
for the office of the UK StH representative will ensure sufficient capacity within SHG to cope with
the extra workload of recruiting, contracting and managing external health personnel. NI-CO has
offered to help out if required. TdC will continue to rely on NI-CO to support the recruitment of
high quality medical personnel while the contracting will be done on island.
On St Helena the establishment and further strengthening of the Electronic Patient Management
Information System has substantially improved evidence-based strategic planning and budgeting
although there still is room for further improvements. On TdC the planned development of a
simple medical operational plan with realistic milestones and targets has not been finalised due to
the frequent staff changes but further work is scheduled this FY alongside development of a
hospital improvement plan.
On St Helena a functional analysis is planned for the FY 12/13 to identify optimal staffing levels
and skills sets to ensure the health and social services directorate remains adequately staffed to
deliver high quality community-based and clinical services taking into account hospital
redevelopment plans as well as redevelopment plans of accommodation for vulnerable population
groups (elderly/disabled).
TdC and St Helena have both prepared detailed lists of TC requirements for the next 3 years.
Funding has been secured for TdC for 2012-2015 within the approved Business Case for
Capacity Building 2012-2015 while for St Helena the TC-health budget allocation has been
agreed for 2012/13 and indicative budgets have been discussed for 2013/14 and 2014/15.
2. Costs and timescale
2.1 Was the project completed within budget / expected costs: Yes
By the end of March 2012 95% of the project budget was spent (93.9% of DFID project budget
and 99.8% of SHG own contribution).
All project funds have been transferred to St Helena based on an initial budget forecast. At the
2012 DAPM an interim statement highlighted an expected under spending of £191,000 of the
DFID allocation by 31 March 2012, the project end date. Parties agreed that SHG retain and use
these funds during 2012/13 for essential medical/health related human resources (i.e. the same
purpose as the project). The DAPM Aide Memoire 2012 details this arrangement. SHG’s final
audited accounts covering the final year of the HealthLink3 project up to March 2012 will be
available in December 2012. SHG Finance Department anticipate the audit will verify a further
£51,222 underspend which parties will reconcile at the DAPM 2013. For this reason, the ARIES
record shows full expenditure of £4m although only £3,757,778 or 94% was consumed within the
lifetime of the project.
2.2 Key cost drivers :
Not surprisingly - considering that the project’s main objective was to provide essential health staff
for the island - personnel was by far the most expensive cost centre (62% of total expenses) with a
more or less equal distribution between STTC and LTTC followed by related travel/subsistence
costs (23%). The remaining costs were for recruitment expenses, management fees, professional
indemnity cover, training fees and communication. One percentage was spent on equipment
(mainly costs for 2 dental chairs to enable the contracted dentist and local dental hygienist to
provide quality services).
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2.3 Was the project completed within the expected timescale: Yes
3. Evidence and Evaluation
3.1 Assess any changes in evidence and what this meant for the project.
The programme was designed to provide appropriate skilled health and social services staff. Overall
there was no major change in evidence. The project responded flexibly to emerging needs.
However, to ensure an optimal and cost-effective mix of secondary care service provision on island,
appropriate use of remote advice and referral services the project supported a review of referral
patterns and referral costs. Referrals are an important cost centre for DHSW. The review analysed
evidence to assess whether 1) any changes were required in skills mix of doctors and health/social
services staff on St Helena, 2) the timing, frequency and skills required of visiting specialists and 3)
arrangements with referral hospitals. The decision to expand the medical officers’ team from 4 to 6 expected to improve quality of care on island and reduce need for referrals – was made based on this
review and an analysis of HL3 expenditure data. Recommendations of the 2010/2011 review included
formalising arrangements with referral hospitals in South Africa (and associated remote advice) and a
review of insurance options, including stop-loss insurance for overseas referrals. Further work in this
respect is required. However, St Helena has already agreed with Tygerberg University Hospital in
Cape Town to refer patients on a pilot basis instead of using private hospital(s), while Tristan da Cunha
has made an agreement with Groote Schuur Hospital in Cape Town for its referrals. It is expected that
this will lead to considerable cost savings for both St Helena and Tristan da Cunha. Another major cost
centre for both St Helena and Tristan concerns medical supplies and drugs and options for cost
savings are being explored.
3.2 Set out what plans are in place for an evaluation.
There are no plans in place for an external evaluation
However, the final review to develop the PCR involved a full review of inputs and achievements against
logframe targets.
Moreover, LT and ST health and medical personnel contracted under the project submitted end-of
contract reports with an action plan summarising key recommendations many of which related to
further advancing and improving service provision. These have been carefully reviewed by SHG and
DFID staff while performance was reviewed against objectives for the post/consultancy. The
involvement of the clinical governance committee in the review of recommendations and endorsement
of appropriate actions has been a great improvement. However, further work is required to ensure
adequate follow-up of recommendations and action plans. This would optimise and enhance longerterm benefits of ST and LT human resources inputs obtained through the project.
4. Risk
4.1 Risk Rating (overall project risk): Medium
Did the Risk Rating change over the life of the project? NO
This was considered a medium risk programme, for a variety of reasons, and was correctly
categorised. Risk factors were adequately identified during design and appraisal and were factored
into the design.
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4.2 Risk funds not used for purposes intended
A major part of the project expenditure (66.3%) was through the agency contracted to assist with
management and implementation of the project, NI-CO. Annual and quarterly plans were prepared
and agreed upon. Detailed quarterly and annual progress and expenditure reports were prepared by
NI-CO which were reviewed by DHSW/SHG and DFID health advisor and programme management for
accuracy. Expenditures were conform annual plans with any changes approved in advance in writing
through e-mail correspondence and/or in notes of the 4-6 weekly tri-partite teleconferences.
NI-CO’s accounts are audited on annual basis by external auditors. The last audit was carried out in
May 2012; all accounts were found to be in order. NI-CO - being a public body - is also subject to a
review by the Northern Ireland Audit office. SHG’s annual audits included a review of the HealthLink 3
project expenses. All accounts were found in order with no misappropriation of funds
4.3
Climate and Environment Impact
The major climate and environment impacts relate to the impact of regional and international travel,
which was a significant component of the project, including flights and travel on dedicated Royal Mail
Ship St Helena. Ensuring recruitment of high quality health/medical personnel with the required skills
set the advertisement and sourcing of personnel could not be limited to (South) Africa but had to also
include UK and the global markets.
The planned expansion of the Medical Officer establishment from 4 to 6 is expected to slightly reduce
the carbon footprint caused by air/sea travel as reliance on locum cover for medical officers on island
will reduce and short-term visits from obstetrician/gynaecologist will no longer be required. Moreover, it
is expected that the number of overseas referrals for obstetric/gynaecological pathology will reduce.
The project supported improvements in telemedicine and distant support services thereby improving on
island care with a review of all proposed referrals to ensure referrals are necessary and will provide the
expected health improvements. The current use and planned expansion of telemedicine is however not
expected to influence the visiting specialist schedule in the immediate future.
The project supported the recruitment of a food microbiologist. He was instrumental in SHG obtaining
laboratory accreditation to enable export of fish to EU markets. He also assisted with improving water
testing and reporting which lead to environmental interventions when samples were found
contaminated.
NI-CO has a corporate responsibility policy and they are currently changing over to a paperless office.
All invoices to St Helena and back up documentation where scanned and sent by e-mail thereby
reducing amount of paper used and avoiding using courier services.
Annual visit of NI-CO management and DFID health advisor for on island review of progress and plans
were considered essential with in between effective use of e-mail communication and teleconferencing.
5. Value for Money
5.1 Performance on VfM measures
The programme does not lend itself to standard VfM measures and was designed before the current
Business Case methodologies on VfM were introduced. The main project input is technical assistance
in the form of long- and short-term health and medical personnel. DFID, SHG and TdC have been
involved in decisions to source expertise, which included contributions from a value for money
perspective. Procurement followed SHG rules/regulations.
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The overall judgement on VfM therefore is that performance was excellent. The gradual handover of
recruitment and contracting to SHG is expected to reduce unit costs for essential human resources as
it would omit the need for contracting a recruitment agency and cover related management costs. The
establishment of a link with NHS Devon is expected to reduce transaction cost for the sourcing of
specialist services and other support services required. St Helena and TdC will continue to use the
services of an agency for the recruitment of medical staff.
The cost-effectiveness consultancy supported by the project has highlighted opportunities for cost
savings with respect to referrals. St Helena has since established a link with an University Hospital in
Cape Town for its referrals. TdC established a link with another University Hospital in Cape Town to
reduce its referral costs.
5.2 Commercial Improvement and Value for Money
Largely not applicable to this programme.
NI-CO was selected through a competitive tendering process. Selection processes for long- and shortterm staff were conducted competitively, to achieve best value for money.
5.3 Role of project partners
The excellent collaboration between St Helena Directorate Health and Social Welfare and Tristan da
Cunha administration and project partner NI-CO were crucial for the success of the project. The
Directorate with support from the Human Resource Directorate and the Office of the UK representative
in London gradually took over the various roles and responsibilities pertaining the recruitment and
contracting of health personnel. Although the handover process took longer than envisaged NI-CO’s
commitment to support this handover process was crucial for its success.
The islands’ long and effective cooperation and partnership with NI-CO has laid the foundation and
provided the assurances that both islands will be able to timely attract and contract the required
essential medical and health personnel in future with back-up support from NI-CO if required.
5.4 Did the project represent Value for Money : Yes
The project provided essential health and social services personnel required for the delivery of quality
health and social care on St Helena and TdC ensuring that reasonable assistance needs of the
populations were met.
On St Helena the project has provided a valuable adjunct to the UK Government’s budgetary aid
relationship with St Helena in terms of building and further strengthening SHG’s ability to manage the
contracting and recruitment of essential human resources for health. However capacity has been
sufficiently strengthened and there is no further need for earmarked project support beyond March
2012, the project end date.
Similarly on TdC on-going funding support for essential human resources beyond March 2012 has
been secured within the approved Business Case for Capacity Building 2012-2015 omitting the need
for separate health project.
6. Conditionality
6.1 Update on specific conditions
St Helena provided its financial contribution as agreed. There are no further conditionalities attached to
the project.
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7. Conclusions
The project significantly contributed to improving health service provision and range and quality of
health care available on both St Helena and Tristan da Cunha thereby contributing towards
improving health outcomes.
On St Helena the project helped secure essential human resources in health and social services
with an appropriate skills mix on island with distant support links and a visiting specialist
programme; rationalising the timing, frequency and skills required of visiting specialists. The need
and costs of employing doctors and specialists with different skills mix need to be continually
assessed against essential services requirements based on population needs and the frequency
and costs of off island referrals. The St Helena Nursing School has seen major improvements over
the past years with increased student enrolment and curriculum updated to a level 6 diploma level.
On island capacity has been built and systems established to sustain the gains made by the project.
Responsibility for recruitment, contracting and management of international staff has been
successfully transferred from NI-CO to St Helena. A functional analysis is planned for FY 2012/13 to
appraise optimal staffing levels and required skills mix to deliver essential package of health and
social services on island within available resource envelop.
A new model for service delivery is being proposed for Tristan da Cunha using a rota of shorter-term
medical officers as it has been increasingly difficult to attract long-term medical officers with the
appropriate skills mix. Over the past year TdC had to heavily rely on locum cover. TdC has been
successful in attracting and contracting a Tristan qualified nurse to provide on island training to the
nurses and support service provision.
On both St Helena and Tristan da Cunha on-going funding support for essential human resources
beyond March 2012 has been secured within the overall approved TC budget and approved
Business Case for Capacity Building 2012-2015 respectively.
8. Review Process
The PCR was drafted by the DFID Health Advisor and finalised with inputs received from DFID
colleagues and project partners.
Project and other relevant documents - including quarterly and end-of-project reports prepared by
NICO - as well as reports of visiting specialist/consultants and end-of-contract reports of (locum)
medical officers were reviewed. Health statistics were obtained from StH electronic patient
management information system verified with other data if/as available. For TdC data provided by
the locum medical officer were used to assess achievements over time.
Direct inputs from beneficiaries and project partners were obtained during interviews, meetings and
field visits on St Helena (Island visit 31 January – 23 February 2012) and through teleconference
with Tristan da Cunha stakeholders.
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