The Pharmaceutical Journal
Vol 270 No 7233 p124-126
25 January 2003

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Pharmacy in Bermuda — its legislation, influences and employment opportunities

By Colin Deeney, MRPharmS

Ever dreamed of living and working on a beautiful subtropical island? In this article the author gives an insight
into what it is like to practise pharmacy in Bermuda

The little archipelago of Bermuda lies isolated in the middle of the Atlantic. It is about 600 miles east of the North Carolina coast and a little further away again to the north of the islands in the Caribbean basin, among which it is often mistakenly assumed to be. It consists of some 360 small coral islands, the larger of these being linked by road, bridge and causeway to appear as one island of about 21 miles long and between one and two miles wide.

Despite its remote location and small size Bermuda has an affluent society of some 63,000 inhabitants, being the third richest country in the world by average wage. The islands wealth comes from its two pillars of economic prosperity. First, tourism, which has been a source of income for the island since North Americans started using it as a winter haven in Victorian times. Mark Twain, a regular winter visitor, commented that the rough trip over the Atlantic in the winter was like "going through hell to end up in paradise". Nowadays the main economic pillar is the highly successful offshore finance that Bermuda has developed, mainly reinsurance.

The then uninhabited islands were first settled by the English in 1609 and to this day remain as one of the last British dependant overseas territories. However, Bermuda has its own government and parliament. Despite a referendum on the matter being well beaten in 1995 the issue of independence remains current. This is not surprising given the ethnic mix that is the Bermuda population. Bermudians descend from not only the white British settlers but also from the predominantly black slaves they brought with them and the later labour from the Caribbean and the Portuguese Azores islands. Thus Bermudians have allegiance and kinship to many places — not only to Britain. This cocktail of people means that, although life is peaceful, race and allegiance remain hot political topics.

The remainder of the population, approximately one-fifth, are visitors on temporary work permits. They fill many jobs in the financial and business sector but also, among other things, tourism and health care. This includes the majority of pharmacists.

Pharmacy legislation

There are two bodies that have primary responsibility regarding pharmacy practice in Bermuda: one that regulates the profession and one that represents and furthers the interests of pharmacists.

The Pharmacy Council's general function is to secure high standards of professional competence and conduct in the practice of pharmacy in Bermuda. The council meets to discuss such issues as malpractice and misconduct. Another important role is the vetting of new pharmacists' competence and qualifications before immigration approval. The establishment of the Pharmacy Council is a legal requirement under The Pharmacy and Poisons Act 1972. There is a chairman appointed by the minister (currently the chief medical officer), one practitioner, also appointed by the minister, and three registered pharmacists elected from among themselves. The council is a government body.

The three registered pharmacists are elected by members of the Bermuda Pharmaceutical Association (BPA). This a professional association that concerns itself with matters of interest to pharmacists, its members. Its objects are to maintain the highest possible standards of ethics and conduct in pharmacy, foster good relations among its members and exert appropriate influence in Bermuda in matters relating to health and welfare. The BPA is funded by members' retention fees and it has an executive elected by them. Over the years the BPA executive has created other committees to help it function, such as the continuing education committee and the examination committee. The fact that the BPA elects three members of the Pharmacy Council means that both work well in tandem.

The primary legislation that affects pharmacy practice includes The Pharmacy and Poisons Act 1979 and The Misuse of Drugs Act 1972. The legislation has been written specifically for Bermuda. It takes what local legislators in conjunction with health practitioners on the island consider to be the best aspects of legislation from other jurisdictions, notably the United Kingdom, Canada and the United States. As in the UK there are prescription-only and pharmacy-only classifications of drugs. Although the drugs in each classification are similar, moving drugs from prescription- to pharmacy-only tends to lag behind the UK.

One notable difference concerns prescriptions and their dispensing. First, prescriptions can be repeated for up to a year. This is at the discretion of the prescriber who specifies whether they wish "repeats" by ticking a box on the prescription stating the number of refills required. The prescriptions are held at the first pharmacy in which they are dispensed but the information can be "transferred" to another pharmacy should the patient wish to collect a refill there. This is similar to the system used in both Canada and the US.

Another difference is that generic or other brand substitution is not only permissible but usually actively encouraged. Again the prescriber can mark the prescription "no substitutions" should they wish a named brand. However, common sense prevails and this allows the pharmacist more influence. It also permits pharmacies to hold fewer brands thus reducing waste and space. Given the size and isolation of Bermuda it also means that on occasion a prescriber will telephone the pharmacist first, before prescribing, to see what the pharmacist considers suitable, and also has available. All drugs are imported either by the sole pharmaceutical wholesaler or the individual pharmacy.

The amount of generic substitution has increased since the spring of 2001 because a few of the insurance companies who cover prescription costs are actively encouraging their clients to accept generics. They are managing this by paying 100 per cent of the prescription cost for generics as opposed to the standard 80 per cent for branded drugs.

Facsimile and telephoned prescriptions are permitted, so long as the pharmacist knows the prescriber's voice. Narcotic prescriptions cannot be faxed or telephoned. Although I think this works well on a small island, I do not think that telephoning prescriptions would work in a larger jurisdiction.

Given that legislation dates from 1979 the BPA set up a committee to produce a new act. This was with full approval of Pharmacy Council. The new act committee completed its work in 2001. Lyanne Bolton, chairwoman of the committee, explains the need for the new act: "The old one was outdated. Over the years it had been amended and was piecemeal. One of the main issues we had to address was the need for a more user-friendly way to introduce changes and amendments in the future. At present any changes need to pass through the House of Assembly to become law, and that takes a long time and is inefficient." This includes the continual stream of new drugs. The BPA hoped that by appointing a NAC it would allow pharmacists the opportunity to have a major say in the legislation. Among the changes the NAC proposes is the establishment of a committee that would report directly to the Minister of Health on recommended changes, including classification of new drugs, so that not all items need go before the House of Assembly. It also covers the appointment of a full time government pharmacist who will act as registrar and inspector. The new act would also enable easier progression confluent with technological advances, for example, the electronic transfer of prescriptions. The Pharmacy Council, which will make final recommendations, is now considering the new act and changes may be made in drafting the final act. However, by being involved at the beginning the pharmacist's hands-on input should be fruitful.

Health care influences

Health care in Bermuda is mainly private, including hospital, general practice and pharmacy services. Most costs are covered by private health insurance. This is compulsory for all employees, who split the premiums 50-50 with their employers. This, however, does not provide a safety net for the elderly, infirm or unemployed. The government does provide basic cover for hospital care for these people. However many people continue to work well past the UK retirement age, partly to fund health insurance.

The health insurance companies appear to see the benefit of, and are willing to fund, preventive health care. This includes yearly cervical smear tests, mammograms at 35 and six monthly dental hygienist visits — all free of charge for those insured.

The island has just 12 community pharmacies and two hospitals — King Edward Memorial (general) and St Brendan's (psychiatric and rehabilitation). As such the individual pharmacist need never be just a "cog in the wheel". Pete French, who works in Hamilton Pharmacy and previously in the UK, explains: "There's a sense of community in Bermuda that makes pharmacy fun. It is more like a social club than a business." That does not diminish from the serious role and responsibility of the pharmacist but, perhaps, rather encourages it.

Given Bermuda's close proximity to the US it is not surprising that its health care is strongly influenced by its much larger neighbour. This is apparent with respect to direct-to-consumer advertising and brand recognition. Most households have cable television with numerous US channels that advertise medicines, both prescription and non-prescription. These advertisements are influential. However, not all advertised brands are available locally and this allows the pharmacist the opportunity to discuss and advise the client about suitable therapy. In general Bermudians are interested in their health and are inclined to discuss medicines with a pharmacist.

Most conditions that the community pharmacist will encounter are similar to elsewhere, however, some local novelties to the new pharmacist do exist. Examples include, Bermuda rot (tinea versicolor) — depigmentation of the skin caused by the yeast Pityrosporum orbiculare, Portuguese man-of-war stings, the euphemistically named "road rash" from "spills" (accidents) on mopeds, and the all too common muffler burn from bikes. The many tourists who visit the island swell the numbers, especially during the summer months. Most come for respite but acquire holiday makers' illnesses, such as indigestion and motion sickness. There are also some old remedies that local folks use, such as purgatives to "cool the blood" as a panacea for all ills and alcoholic extract of dead centipede to cure their bites — these are unorthodox and invalidated and outwith the pharmacist's ken!

The retailing approach to pharmacy also displays North American influence. Most pharmacies resemble a "drugstore" and sell many items more akin to a newsagent than what would be acceptable in the UK. Unfortunately, one North American influence still to be implemented is the concept of pharmaceutical care.

The prevalence of type 2 diabetes is high in Bermuda, most likely due not only to genetics but also the island's affluent lifestyle where dining out is the main social event. Also, it has been estimated that about one in four children and one in 10 adults are affected by asthma in Bermuda. There are several factors that may be causing the high prevalence. The islands sub-tropical climate causes fairly pleasant, but highly variable, all year round temperatures of between 15 and 30C with high humidity. It is not ideal for asthma sufferers. A quick tour of the island can leave the impression of being in one large botanical garden as the indigenous flora is enhanced with many imported species. The climate also lends itself to mould growth, mildew, and insect life — all sources of potential allergens.

Hospital practice

The King Edward VII Memorial Hospital (KEMH) is similar to a district general hospital in the UK. It is affiliated to Canadian Health Standards. The health insurance companies will pay for any procedure that can be undertaken locally to be carried out abroad also. Their stance is not surprising as it is usually less expensive off-island. Therefore there is virtually no waiting list for any procedure.

General practitioners remain responsible for patients' care even when they are in hospital. They delegate the day-to-day care to the resident doctors but usually undertake daily ward rounds themselves. The GPs can refer the patient to a specialist.

Hospital pharmacists have a proactive role supporting and influencing prescribers and nurses. The main challenge facing the hospital pharmacy department is lack of time. The apparent worldwide shortage of pharmacists means that attaining adequate pharmacist staffing levels to undertake activities is proving a bottleneck to progression.

Hospital pharmacist, Netta Williams, describes the KEMH pharmacy department as: "Diverse and entertaining — and that includes my colleagues as well as the work. There are staff from the UK, Bermuda, Canada, the US and Jamaica. Despite all speaking English we don't all speak the same language. We have our accents and phrases to understand. A lot of the time is spent going 'Huh?' or 'Pardon?' Indeed that sums up living and working in Bermuda as well as I can. Or to put it another way — Bermuda is small enough to get fully involved in yet diverse enough to be entertaining."

Employment opportunities

Non-Bermudian pharmacists must have a work permit. The rules for this are quite specific and are there to protect Bermudians right to employment on the island. Therefore, if a Bermudian with appropriate experience and qualifications applies for a job they are entitled to it, no matter what non-Bermudian applies. In order to make sure that Bermudians get this opportunity all jobs offered to non-Bermudians must first be advertised locally for Bermudians to apply. Should a suitable Bermudian not be found then the employers apply to the immigration department for a work permit for a non-Bermudian. If this sounds cumbersome — it is. The system, although understandable given Bermuda's favourable lifestyle, leads to tensions between immigration, employers, Bermudian and non-Bermudians. There appears to be some manipulation of the rules by all parts at times. Thus ethnic allegiances, race relations and employment are the main problems that Bermuda faces.

There is no pharmacy college on the island. Bermudians intending to become pharmacists must obtain their undergraduate education abroad, most often in the UK, Canada or the US. Even then, there are just a handful of Bermudian pharmacists and the island must use non-Bermudian pharmacists to make up the numbers. These tend to have been educated in the same countries as the Bermudians, ie, the UK, Canada and the US. However, there is no particular reason for that other than professional links. Pharmacists can be registered in any country and can apply for a position. However, they must satisfy not only their employer but also the Pharmacy Council as to their ability and suitability.

All pharmacists, no matter what their experience before arriving on the island, must undertake a one-month preregistration period under the supervision of a Bermudian registered tutor. They must also pass a preregistration examination that covers law, ethics and pharmacology.

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