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I am not sure why I wanted to go to the island of St Helena but I do remember that back in 1992, I had a map of the world on the wall and I had drawn a circle around St Helena. I just knew that one day I would go there.

Some 15 years later I find myself living on St Helena with my wife Belinda who is Saint Helenian and my two year old son Tobias. I am working as the manager for a new nursing home that is under construction. The people that will move into the home are currently living in three separate antiquated facilities called Sundale, The Haven and the Elderly Care Unit which is a ward in the general hospital.

Saint Helena is a very remote island in the South Atlantic Ocean, 2000 kilometres west of Africa, measuring 122 square kilometers. It was famously the prison island of Napoleon after his final defeat and subsequent second exile. Less famously, it was home to a large prisoner of war camp for the Dutch/Afrikaans boers during the Anglo Boer war in South Africa. There is no airport and only the one ship, the Royal Mail Ship St Helena that calls regularly, bringing people and supplies. If she sails to Ascension Island, where there is an airport, she takes four days to get there and back, Cape Town takes nearly three weeks and twice a year she goes to England and is away for five weeks.

The island is a British Dependent Territory with no industry and only limited tourism. We are very dependent on aid from the UK. Some 4,000 people live here so it is a very close knit community. Approximately 25% of the population is over the age of 60, the mandatory retirement age for government workers, and in recent years more and more people of working age have left the island to find employment on Ascension Island, the Falklands and increasingly the UK. The principle reason for leaving is the low wages paid on island. Even a qualified nurse can earn more on the Falklands as a cleaner.

The migration of people off island is having serious consequences for the care service of older people. It is becoming increasingly difficult to find staff to work in the care facilities or as home helps. All three care facilities are short staffed and the average age of a home help is 55. As elsewhere, people are living longer, and with more chronic disease the needs of our older people are becoming more complex.

There are usually four doctors working on the island, one of whom is always a surgeon. There is no requirement for any of the doctors to have specific geriatric experience but it clearly would be advantageous if one had. We were fortunate in 2005 to have a visit by a member of the BGS, Dr Paul Goldstraw who was contracted to review and make recommendations for a geriatric medical service. We have not been able to implement a number of his recommendations because of staff shortages and financial restrictions but his report is one that I frequently refer to. It is my hope that we will be able to develop a specific elderly care service for the island which brings together health and social care and which has access to a geriatrician on a regular basis. The geriatrician could provide a range of services from staff training and supervision, right through to direct consultations with patients. All of this could be done through tele-medicine backed up by a visit every couple of years.

In the meantime, we have to prepare for the new nursing home, the Community Care Complex (CCC). There are real problems with the CCC. It is not big enough as it will only accommodate 42 people and we have 55 people in care. Originally a 60 bedded facility was asked for but funding was only granted for a smaller home. Now of course additional funding has to be sought to build a 20 bed wing. In the meantime part of The Haven will remain open. There are also problems with the design of the CCC as it is does not make the most efficient use of staff and additional staff will be required. Finding those additional staff is going to be difficult.

Those are some of the challenges, but the rewards, in terms of caring people and knowing that one can make a difference, are great. In the UK, I was often told that I was getting too involved, as if this was somehow a bad thing, but out here one cannot help but get involved. In my job I can start the day helping someone in the bath, meet with a doctor to investigate why someone is ill and plan treatment, then visit someone at home to provide advice on how to make the home more accessible and end the day in a meeting discussing strategic objectives for public health. I say “end the day” but you are always on call and often family members will ring in the evening to discuss concerns about elderly relatives. We may be a small and isolated community but there is an intensity to this job that I have not experienced elsewhere.

There are times when I do get worried that we are going to be overwhelmed by the numbers of older people that we care for. This is why we must strive to provide the best medical and social care service that we can in order that people can have a healthy old age. We really struggle with our limited resources but I would not want to work anywhere else.

Ian Rummery