Letters

Rationing of sildenafil

Nobody needs an erection at public expense

True debate is needed

Older doctor derived great benefit from sildenafil

Summary of electronic responses

Nobody needs an erection at public expense

EDITORI am a BMA member, but Drs John Chisholm and Ian Bogle do not speak for me on sildenafil (Viagra). ^{1 2} I understood that we had been asking successive governments for years to accept the need for explicit rationing decisions. As soon as this government makes onea sensible one that the general public acceptswe kick it in the teeth.

The grounds for differentiating between different causes of erectile dysfunction outlined by the health secretary, Frank Dobson, were imperfect but not unreasonable³; for the first time there was an overt admission that totally comprehensive demand-led care had to be limited. This was not the time to pick a fight. The media comment suggests that the public accepts that when resources are limited conditions such as cataract and stroke should be given higher priorities than erectile dysfunction.

I have been telling my patients who request sildenafil that the NHS cannot afford it. I still take that view, but the BMA's reported comments will make my position harder to sustain. Sildenafil should be available at cost without prescription; it will cost about as much as an acceptable bottle of table wine.

Stephen Hayes, General practitioner. 
Southampton SO30 2AA stephen.hayes1{at}virgin.net

True debate is needed

EDITORThe proposals for rationing of sildenafil (Viagra) put forward by the secretary of state are unethical,¹ and the General Practitioners Committee is correct to advise general practitioners to prescribe the drug on prescription to all patients who require it.²

Many doctors would welcome a mature debate regarding rationing in the NHS, recognising that in an underfunded service where rationing has always existed such a discussion should be held openly and honestly. Few, however, can have expected that the first politically instigated, clearly financial, limitation of treatment would be decided on the basis of aetiology and not clinical need. To implement such a decision would be to break the fundamental principle of medicine that patients should be treated according to need, regardless of the chain of events that placed them in that position of need.

Impotence has many similarities with menopausal hot flushes. Neither are life threatening, both cause distress, and both are common conditions often but not always associated with a particular age and viewed by some as natural. A general practitioner willing to give hormone replacement treatment only to those women whose symptoms were due to an oophorectomy or radiotherapy and not those whose symptoms were the result of natural ovarian failure, and who justified the decision on grounds of cost, would not only be acting unethically but also be in breach of his or her terms and conditions of service.

The proposed loophole whereby patients with impotence caused by other processes can have NHS treatment only if judged by a urologist to be in extreme distress places a burden of psychological assessment on this clinician; the clinician will have little access to detailed psychiatric history, poor knowledge of the patient's social situation, little time for a mental state examination, and no training or experience in psychiatry. It would be surprising if decisions made by such a professional were any more valid than those made by the patient's general practitioner. This measure represents only a crude attempt to appease opponents of the rationing decision and does nothing to solve logically the problems that such new treatments produce.

Andrew Green, General practitioner. 
Hedon Group Practice, Hedon, East Yorkshire HU12 8JD orchardh{at}globalnet.co.uk

Older doctor derived great benefit from sildenafil

EDITORA retired doctor in my 60s, I had come to accept impotence as part of normal ageing. But taunts in an unhappy marriage led me to explore the problem with a specialist colleague. Soon afterwards widowed, and eventually enjoying a new relationship with a much younger widow, I was confronted again with the bogey of erectile dysfunction. After further psychiatric counselling a trial of the latest new remedy proved unhelpful, so I reluctantly accepted my limitations once again.

Later, a consultant urologist consulted for nocturnal frequency advised review of the erectile dysfunction. Onward referral to a uroandrologist established organic causation amenable to treatment. He recommended androgen replacement and was reassuring about its risks. Unfortunately, despite improved hormonal concentrations, testosterone alone failed to restore potency. The alternative oral regimen proved hard to sustain without any discernible benefit. Injections of another remedy into the penis proved too repugnant to tolerate.

The latest reputedly magic curesildenafil (Viagra)became available eventually to nominated specialists. Before prescribing it my uroandrologist sought psychiatric reassurance about my relationship with my new wife, holding a prevalent belief that such problems usually had a psychological component. Before our joint psychiatric appointment, sildenafil became freely available abroad. Tablets bought over the counter on holiday in Switzerland and taken in a low dose restored normal potency immediately, after 15 years' impotence. The benefits to a retired doctor in his early 70s and his premenopausal wife do not need to be spelt out.

No untoward side effects occurred, so the uroandrologist recommended continuation of hormone replacement plus sildenafil (by then licensed in the United Kingdom), and the joint prescription was implemented by my general practitioner. Later, having studied official advice, she stopped the sildenafil; she would continue to prescribe the androgen, but I should seek sildenafil privately.

Accustomed to my health needs being met by the NHS, to which I had given a lifetime of service, I asked her to reconsider her decision. After reviewing my extensive specialist investigations she exercised her clinical judgment and resumed NHS prescription of testosterone with sildenafil, pending the health minister's advice and the BMA's response to it.

It is anomalous that a joint NHS prescription, shown as curative for a seemingly irremediable organic condition, is apparently to become impermissible again unless the proposed list of "acceptable" reasons for impotence is reviewed sensibly and promoted on an advisory basis. Even if a more logical list was devised it should not deny doctors the right to exercise clinical discretion individually.

Anonymous,  Consultant psychiatrist. 

Summary of electronic responses

The Viagra debate attracted about 30 responses.¹ The following quotes cover the broad range of opinions.

• Nobody seems to be against rationing:

"Until we have all the surgeons and community nurses who could help some patients, there is no case for providing drugs for all" (P West).

"We should welcome and applaud the bravery of the secretary of state for health in opening up the whole issue of rationing" (L Miller).

"The core services provided by the NHS need to be redefined ... the less money spent on Viagra the better. Impotence is hardly life threatening" (M Sparks).

"The real issue is that we will soon no longer be able to operate by using the prescription pad as a blank cheque" (T Hyde).

"Guidelines seem to be necessary for rationing. If no guideline is enforced, leaving it to the individual GP will lead to enormous variation in prescribing, as shown for many other drugs. Fairness requires a consistent response" (P West).

• Guidelines and the tricky business of private prescription, however, are of concern:

"The secretary of state, no doubt in a state of panic, may have initially come up with a rather shoddy list of indications for Viagra, but hopefully this will be modified when the dust has settled and the spot-light is off"(J Stapleton).

"If the drug is to be rationed, then consider all the possibilities" (S Shaffi).

"Supposedly there are many acceptable indications for eligibility. Patients will be eligible to obtain Viagra on the NHS if they have had their `prostate removed.' Does this include all forms of prostate surgery, or does it only include patients who have had a radical prostatectomy for cancer? ... Further, there is the question who is going to assess if a patient is suffering from `severe distress?'" (R Beck), and this is one urologist who certainly would not be making such an assessment.

"Maybe a blanket ban would be fairer than one with more holes than a Swiss cheese" (D Hopkins).

"GPs prescribing sildenafil would be in breach of guidance if they use an FP10, and in breach of their terms of service if they issue a private prescription to their own patients" (P English).

• Specialist consultants are better off:

"I cannot write a private prescription on NHS premises. Thus the patients end up having to make a private appointment and pay for the drug! Crazy, but good for my income" (G Caldwell).

"Why not make sildenafil (Viagra) available over the counter from pharmacists?" (C West).