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Prior to the conflict, like much else in the Islands' health service, eye care provision was under the auspices of the Overseas Development Agency. The visiting optometrist would spend several weeks travelling on the Islands to examine patients and the spectacles dispensed were in line with those available under NHS regulations in the UK.
In the period immediately after the conflict, medical services were provided by the armed services and became centred on the rebuilt King Edward VII Memorial Hospital (KEMH) in Stanley eye care services were included in the range of services provided by visiting clinicians from various military establishments.
In 1990, KEMH was staffed by both military and civilian personnel, but the transfer of the Islands' health service back to a civilian-only basis was beginning. Sadly, the previous post-holder had become incapacitated therefore an opportunity arose for a new service provider to take responsibility for eye-care on direct contract to the Falkland Islands Government Medical Service. The optical service at that time was provided by a family-owned firm of dispensing opticians with experience of the primary care, community-based sector and in the secondary care sector of the HES.
Changes in provision
The eye care service re-emerged in a similar format to that prior to the conflict a team of an optometrist or ophthalmic medical practitioner and a DO visited for a short period each year. Initially, clinics were held both at the hospital in Stanley and also at various outlying settlements. Any patient requiring investigation or treatment in secondary care was referred to an ophthalmic surgeon in the UK. The dispensing provision was modernised in a similar manner to the changes in the General Ophthalmic Services implemented at that time. The statutory range of frames was withdrawn so that a wide range of designs became available.
Infrastructure improvements in rural areas (otherwise known as Camp) and the drift of the population towards Stanley over the years led to a change in the pattern of provision. It became more time and cost-effective to concentrate services at KEMH rather than in outlying settlements, since many people could now drive into Stanley and return home in one day due to better roads around East and West Falkland.
One clinic was arranged at a central location on West Falkland, usually Port Howard or Fox Bay and the residents of other settlements travelled overland to that location. This also resulted in the demise of the 'Bunk House Party' and the social gatherings associated with an overnight stay for patients attending the Camp clinic. The increased throughput of patients at the KEMH clinic allowed a reduction in the duration of each visit by the opticians, although regular annual visits were maintained and more recently there has been more than one short visit each year.
Economic benefits
The economy of the Islands benefited substantially from the developments within the fishing industry the growth in the economy enabled a government subsidy to be granted for the population for the provision of spectacles, although this has now been refined to give entitlement to children, persons aged over 64 years and those in receipt of social welfare benefits, a more generous provision than that available in the NHS, although the examination fee entitlements are similar.
Increasing patient numbers attending for primary care assessment caused an increase in demand for secondary care. The higher number of persons requiring surgical assessment resulted in greater viability for a visit to the Islands by a surgeon. A link with the Radcliffe Infirmary and Oxford Eye Hospital was established since there is easy access to Oxford from RAF Brize Norton, the UK base for the MoD air bridge with the Falkland Islands. A surgeon based at Oxford has visited in recent years and patients are also sent to Oxford for investigation. Other UK hospitals may also be used where the patient has a family link. Treatment is funded by the Falkland Islands Government rather than a reciprocal NHS entitlement, although there is such a limited arrangement for the Islands' citizens.
One local medical officer has pursued a special interest in ophthalmology, attending the department at Oxford for training he is able to provide year-round clinics for minor problems. One of the nurses has also been designated as the ophthalmic nurse, although she has had only limited specialist training she supports the primary care service by carrying out vision screening for school-aged children, performing visual field assessments and some minor procedures.
There has been a gradual increase in the specialist instruments at KEMH, thanks largely to the generosity of UK military hospitals. However, equipment still facilitates only certain procedures to be performed in the Islands. More complex procedures must be carried out in specialist units overseas. Provision of treatment in the Islands is a huge social and economic benefit since referring a patient off-island incurs travel and subsistence expenses for the patient, and if necessary a carer, as well as the costs of the treatment. There is also a great benefit in terms of the protracted timescale of any overseas referral whereby a patient may be away from their employment for several weeks in order to attend a single appointment offshore.
Links to Chile
A more recent development has been the option to refer patients to Chile for specialist opinion. There is now a regular air service between the Falkland Islands and Chile, so it is possible to use medical services in Santiago. The flight to Chile is only seven hours, compared to some 18 hours between Mount Pleasant and Brize Norton, and is much more passenger-friendly. It is a commercial flight and therefore not subject to the restrictions on civilian booking quotas imposed on the MoD air bridge. The 'turn-round' time for a patient attending a single medical appointment is therefore reduced for those travelling to Chile compared with the UK.
In the latter part of 2007 there was a change in the primary care contract holder for the eye care service it is now managed by NI-CO, a division of the Trade and Enterprise Unit of Northern Ireland, incorporating the business unit of the health board. NI-CO has many years' experience of providing similar services for the isolated communities of the UK Overseas Territories of the South Atlantic through the St Helena and Tristan da Cunha Health link project. The protocol used successfully on the other islands will be followed on the Falklands with modifications for local requirements. The service is provided by a consultant optometrist, on behalf of NI-CO with management support from the organisation. The ethos of the service favours improved clinical services, for example with the implementation of a formal diabetic retinopathy screening service and regular audit reporting, while maintaining a primary care optometric service for the whole population.
The conundrum of the best method of providing specialist services for this small, remote population is one with many aspects. In terms of health economics, such a service is highly unlikely to be cost-effective one must weigh the expense of healthcare practitioners visiting the Islands against the costs incurred in referring persons overseas. This also includes consideration of travel and subsistence costs for patient and carer, and the costs of a protracted absence for both employer and employee. There are also social benefits for the recovering patient at home rather than being separated from family support networks.
Visits by specialist practitioners are, by necessity, of a finite duration so it is necessary to establish comprehensive protocols for shared care of chronic conditions and postoperative care of patients, particularly in respect of the management of potential complications, since care will be transferred to local staff with limited knowledge and experience of these conditions. One must also consider treatment protocols where follow up may be irregular it may be necessary to consider a more aggressive intervention at the outset since frequent reviews are not possible.
Recruitment difficulties
In the age of the sub-specialist in many branches of surgery, it becomes increasingly difficult to recruit practitioners with broad competencies to provide a comprehensive secondary care service thus it may be necessary to consider a mixed service with procedures both on and offshore.
The expectations and visual tasks may differ from those in other communities, therefore one may need to consider different criteria for surgical intervention.
Balancing the increasing awareness and desire for modern technology and techniques with the practicality of its use in such locations is a difficult task.
Specialist equipment may be infrequently used, or used by local personnel with limited training careful consideration may be required to select instruments that may be operated effectively and present results in a format suitable for such non-specialist workers. It is also pertinent to consider the supply of consumables and the maintenance of instruments supplies may be erratic and it is desirable that local personnel can carry out basic maintenance, although it may be necessary to arrange appropriate specialist servicing from time to time. It is important to consider feasibility for maintenance when recommending obsolete equipment it may have an initial appeal for financial reasons but later prove burdensome when components are not available for repairs and it quickly becomes a white elephant.
Developments in telemedicine technology hold great appeal for such remote services. However, the capital outlay is often high and difficult to justify for such a small population so the proposals rarely progress. It may be beneficial to establish links with suitable institutions to initiate telemedicine in its fullest sense and also to encourage local ownership of the primary service with remote specialist support.
Links between the various similar remote communities would be beneficial in terms of shared experience and also shared resources, particularly if geographic location facilitates communication and travel between the locations.
The conundrum has not been solved but it is a privilege to have the opportunity to develop services for such communities and is a very worthwhile experience.
Priscilla J Brown is a consultant optometrist for NI-CO, honorary OO, Diabetes Eye Complications Screening Service, Guy's and St Thomas' NHS Foundation Trust and a community OO in Berkshire.