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Letter from the Isle of Man
  1. Robert Martyn Bracewell1,2,3
  1. 1Medical and Health Sciences, Human Behavioural Sciences, Bangor University, Bangor, UK
  2. 2Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
  3. 3Neurology, Noble's Hospital, Strang, Isle of Man
  1. Correspondence to Dr Robert Martyn Bracewell, Medical and Health Sciences; Human Behavioural Sciences, Bangor University, Bangor, UK; m.bracewell{at}

Statistics from

The Isle of Man is a British Crown Dependency in the Irish Sea (figure 1). The population is about 85 000; half were born on the island (true Manxies) and half are ‘come-overs’ (80% from the UK, 20% elsewhere). Manxies are very proud of their independence and resilience. This is exemplified by the Manx flag (figure 2) featuring the three legs of Man (ny tree cassyn in Manx). The Manx motto is Quocunque jeceris stabit (‘Whithersoever you throw it, it will stand’).

Figure 1

Map indicating the position of the Isle of Man in the British Isles.

The Manx National Health Service (NHS) is broadly similar to those of the UK’s nations. The island has about 40 general practitioners (GPs), who serve as gatekeepers of access to secondary care. There is one main hospital (Noble’s), with 314 beds, just outside the capital city, Douglas. Noble’s is comparable to a small district general hospital in the UK. There is one community hospital at Ramsey in the north of the island.

Much secondary care is delivered by consultants who are resident on the island. Several specialist services (including neurology) are provided by visiting consultants, most of whom are based in Liverpool. There is a weekly 2-day visit by one of two experienced consultant neurologists (Dr Wojciech Pietkiewicz and the author) from the Walton Centre for Neurology and Neurosurgery in Liverpool. The neurologists alternate their visits. Typically, the neurologist flies to the island early on Wednesday morning and returns on Thursday evening. Clinical administration, ward referrals, clinical and other meetings are done on the Wednesday. Two clinics are held on the Thursday. In the course of a month, there are one epilepsy and seven general neurology clinics.

There is access to CT scanning, 1.5T and 3T MR imaging, DaT and SPECT scanning. Outpatient and inpatient EEG is available 1 day a month (provided by visiting physiologists from Manchester Royal Infirmary). Patients requiring more complex EEG studies (including evoked potentials) and any peripheral electrophysiological studies must travel to the Walton Centre.

We see inpatients during our visits, and liaise with the resident medical, surgical or psychiatric teams by telephone or video-conferencing when off-island. Both of the neurologists try to avoid transferring inpatients to the Walton Centre if possible, in view of the inconvenience to patient and families. Patients will be transferred if they require investigations (eg, formal angiography) or treatment (in particular, neurosurgery and interventional neuroradiology including thrombectomy in acute stroke) not available on island.

Patients can be admitted to a day case unit in Noble’s for elective lumbar punctures and infusions, including intravenous immunoglobulins and several of the disease-modifying treatments for multiple sclerosis.

A visiting service of this nature relies on the local service. There is an excellent secretarial team, and one experienced neurology nurse specialist whose main remit is multiple sclerosis and motor neuron disease. She is a key link, and we continue to lobby for the appointment of nurse specialists in headache and epilepsy.

Apart from having to fly, in many ways the above will seem familiar to many UK neurologists who visit a district general hospital. What is, or feels, different?

In outpatients, the neurologist is fuelled by endless cups of tea, and usually homemade cake. There is a sense of working against the clock; the penalty of a late finish is missing the flight home. Clinics are busy; the ‘did not attend’ rate is low.

There are about 600 new outpatient referrals a year. There are, at present, no formal waiting time targets, and some routine outpatients wait for more than a year to be seen. Understandably, this results in many ‘please expedite’ letters, and some GPs game the system by requesting urgent appointments for chronic problems. Patient expectations are in general high, and invariably each week there are several requests to telephone a patient or family member. Because the island is a small community, matters can potentially rapidly escalate to involve a patient’s Member of the House of Keys (Member of Parliament) or even the Minister for Health.

During the first 3 months of the first COVID-19 lockdown, travel to the island was not allowed. As soon as key workers were permitted to travel, I resumed my visits. I was subject to daily PCR tests and was only allowed to be in the hospital or ‘quarantined’ in my hotel room. Not even a late-night walk on the Douglas promenade to clear my head was allowed. Visiting key workers and locals who broke the rules were jailed (perhaps a lesson for the UK?). Often, I was the only passenger (figure 3) on the plane (and indeed at the airport) and would be greeted by name by the pilot and customs and immigration staff. Quite reasonably, Dr Pietkiewicz did his clinics by telephone (I am sure his nose and tonsils are grateul). For many months, COVID-19 rates on the island were very low, and repeated lockdowns were avoided. Vaccination rates are high. However, infection rates are now similar to those in the UK, but at no point has the Manx NHS felt overwhelmed.

Figure 3

The author as sole passenger en route to the island.

There has recently been a major reorganisation of healthcare management on the island. Delivery of care (in primary and secondary settings) is now the responsibility of a new organisation, Manx Care, which is designed to be at arm’s length from the Department of Health and Social Care. We are trying to develop referral pathways and shared-care agreements with our colleagues on the island. Dr Pietkiewicz has trained many of the island’s GPs in botulinum toxin injections and local nerve blocks for the management of headache. I work closely with the old age psychiatry service (for atypical cognitive/behavioural presentations) and the gerontologist with an interest in cerebrovascular disease and movement disorders, running quarterly joint clinics. We contribute to on-island training days for health and social care professionals. Recent meetings have covered headache, dementia, epilepsy and movement disorders. Unfortunately, the hospital grand rounds happen on a Friday when we are not on the island. We encourage juniors to join us on the wards and in outpatients.

One issue of concern (to both patients and clinicians in several specialties) is a lack of parity with the UK on the availability of drugs. Hitherto, we have had to make the case for individual new drugs to be made available to the drugs and therapeutics committees. Recently the decision has been made that any treatment approved by NICE in the UK should be available in principle. However, budgetary constraints persist, and some treatments available in the UK are not (yet) on the island.

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  • Contributors RMB conceived and wrote the paper.

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

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  • Competing interests None declared.

  • Provenance and peer review Provenance and peer review. Not commissioned. Externally peer reviewed by James McDonald, Edinburgh, UK and Colin Mumford, Edinburgh, UK.

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