The Pharmaceutical Journal Vol 267 No 7179 p911-936
22-29 December 2001

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Pharmacy in the Falkland Islands — a health service without pharmacists

Residents of the Falkland Islands enjoy a good, modern, free health service and this is achieved without the employment of a single pharmacist in a pharmaceutical capacity. The last census in 1996 gave the population of the Islands as 2,564 and this approximately doubles when military personnel are included. King Edward Memorial Hospital in Stanley which was built after the 1982 conflict following a fire in the old hospital, employs 4.5 general practitioners for the local population — an enviable 500 to 600 people per GP. Military personnel have their own GPs based at Mount Pleasant, an hour's drive from Stanley.

The high GP/patient ratio needs to be considered in the light of substantial numbers of casualties from fishing vessels, the need to provide a medical service to around 400 residents who live in Camp (the countryside) an area approximately equal to that of Northern Ireland, and the provision of emergency services. Secondary care specialists at the hospital include a general surgeon and an anaesthetist. All secondary care referrals which cannot be dealt with locally are flown to the United Kingdom or, if more urgent care is needed, to South America.

GPs are flown to Camp settlements to provide medical care or consultations are conducted by telephone. Before the advent of the telephone, communication to Camp was by radio and the medical consultations were a popular channel to listen to — privacy was not possible and locals have many amusing anecdotes of the consultations which took place.

The hospital pharmacy is run by a pharmacy technician who has quite a job ensuring continuity of supply since medicines are delivered approximately monthly. There is an electronic prescribing and dispensing system and an electronic prescription appears at the pharmacy following patient consultations — paper prescriptions are not used. Nurses prescribe dressings and certain drugs are prescribed by specialist nurses, again the EMIS system is used to communicate with the pharmacy.

The medical service is free to residents and this includes prescriptions — there are no prescription charges and dental and optical services are also free. Islanders are quick to point out to visitors that, apart from defence, they are financially independent from the UK with the bulk of the country's income coming from squid fishing licences.

Over-the-counter medicines

The hospital pharmacy is the only pharmacy on the islands and there is no equivalent to the community pharmacy since the number of residents would make this uneconomical. Some OTC medicines are sold in supermarkets in Stanley although there appears to be little logic in the choice of drugs stocked. Paracetamol can be missing altogether at times, travel sickness tablets are not to be found and yet at one point Canesten suppositories with Spanish labelling appeared on the shelves. The other frequent feature is that out of date drugs are often offered for sale — one shop recently had Karvol capsules with an expiry date of May 1998 on the shelf. Islanders often have to purchase goods past their expiry date and indeed years ago when contact with the outside world was infrequent many goods were out of date even before reaching the islands.

The Medicines Act of 1968 does not apply in the Falklands and therefore pharmacy medicines can legally be sold in general stores. However, the chief medical officer has the authority to prevent the sale of goods which he considers to be unsuitable for sale over the counter.

A few items can be purchased from the hospital pharmacy, eg, hyoscine patches. Otherwise patients wishing to obtain OTC medicines that are not available in the local shops have to see a doctor and the drugs are then prescribed and obtained free of charge.

Prescribing

The influences on prescribing are rather different from those in the UK — for obvious reasons drug representatives do not visit; also pharmaceutical advisers are non-existent. It might be expected that the lack of community pharmacies would lead to more prescribing but the strong pressure to reduce spending on drugs seen in recent years in the UK is not a feature of the Falklands.

Spending on primary care drugs in 1999 for residents and temporary residents (which includes fishermen but excludes the bulk of military prescribing) was around £160,000 — approximately £60 per head of population per year. This compares with primary care groups in the UK which in 1999 had a budget of around £100 per head. However, the comparison is difficult as the number of people in the Falklands is only as many as a small GP practice in the UK and therefore individual high cost patients — or the lack of them — have a big influence. Indeed the use of specialist high cost drugs is low. Nevertheless it does suggest that prescribing in the Falklands is not excessively costly.

The relative spending on drugs in the main British National Formulary chapters in the Falklands is strikingly different from that in the UK. It is spending on respiratory, and not cardiovascular drugs, which is by far the highest cost area at 31 per cent of total drug costs. The use of salmeterol and fluticasone tends to be high but the very high spending reflects the high incidence of respiratory diseases — asthma is particularly common. Spending on cardiovascular drugs only accounts for about 20 per cent of total spending, this is at least partly explained by the relatively young population (around 11 per cent over 65 years).

It comes as no surprise that by far the highest cost drug is omeprazole 20mg, a situation not uncommon in the UK, at least before efforts were made to make cost savings. This is an area where, perhaps, savings could be made in the Falklands, too. The use of low dose proton pump inhibitors is low.

There are a few unusual features in the prescribing which can often be seen in a small practice. Peppermint oil capsules, glyceryl trinitrate patches and gamolenic acid capsules are popular.

Prescribing is cost-effective in some areas. Pharmaceutical advisers would be envious of the complete absence of prescribing of co-codamol 30/500mg, the low use of modified release isosorbide mononitrate (10 per cent of all isosorbide mononitrate prescribed), and the high use of thiazide diuretics (33 per cent of all antihypertensives).

Pharmaceutical advisers would not, however, be envious of the currently available prescribing information. With no prescription pricing authority there are no prescribing analysis and cost (PACT) data and no EPACT. However the existing electronic system could enable regular monitoring to take place and this could give diagnostic as well as prescribing information.

The hospital operates a drug formulary which is currently being updated by a pharmacist on a voluntary basis. Information on new drugs tends to be from UK consultants when patients are transferred back to the care of local GPs following treatment in the UK. Formal medicines information services are not a feature in the islands and there is no link with a medicines information centre in the UK. Informally, two pharmacists currently resident in the Falklands provide information and there is now access to the UK medicines information pharmacists' electronic network.

Expensive drugs, such as growth hormone and beta interferon, are not currently being prescribed although there are no restrictions on the use of high cost drugs. Patients with cancer for instance are able to access all of the drugs recommended by UK consultants — a restriction on this has not been considered and it would be difficult to refuse funds for an expensive drug in such a close knit and relatively affluent community.

Substance abuse

Drug abuse in the Falklands is not a problem and methadone is not prescribed. Customs occasionally seize illicit drugs but in 1999 there was only one instance and that did not involve an islander. The government is keen that this situation continues and penalties for possession of drugs are severe. The main risk of drug abuse is among sixth-formers who go to school in the UK. Because of this all children have educational sessions on illicit drugs before their sixth form starts.

Conclusion

In summary the Falkland islanders are fortunate in their health service, which is of a good quality, is free of charge and has no waiting lists. The addition of a primary care pharmacist/pharmaceutical adviser would be useful. The islanders, as well as the many cruise ship tourists who visit, would benefit from access to a community pharmacist. However, the size of the population makes the employment of a pharmacist an expensive luxury in a health service with a high GP/patient ratio.