Doctor at large

A 70-year-old judge, taking 'Viagra style' pills, is having sex six times a night with a 'porn star', according to the News of the World. The poor old judge, it is reported, still loves his wife but left after she'd complained he was 'demanding too much sex'.

The same day, the Mail on Sunday soberly announced that fewer than 5,000 NHS prescriptions for Viagra were issued in the first four months it has been available in the UK. The paper claims that the Department of Health will produce figures showing that Viagra cost the NHS only £200,000. This is small beer, compared with the department's initial estimates that widespread prescription could mean a £100m annual bill. Restrictions on the drug, laid down in January by the health secretary Frank Dobson, mean that most Viagra is privately prescribed, with patients able to get four tablets for £32. Since the restrictions on Viagra were treated by the media as the first example of the explicit rationing of a treatment (the government preferred the term 'setting priorities'), its cost to the nation will be closely monitored.

The government did well to sell the idea that it was being responsible in stopping GPs dishing out Viagra to everyone who'd want it. The media were terribly helpful. On the one hand, there were stories of frivolous people having shed-loads of sex and leaving their partners; on the other, there were pious editorials applauding Dobson's courage in preventing money being diverted from caring for incontinent old ladies starving in understaffed wards (or 'Stopping old ladies getting shafted,' as certain Sunday papers might say).

Some GPs I know are grateful for Dobson stopping an expensive Viagra-fest. They say that many, or at least middle-class, patients can afford £8 a shot, less than two pints of beer and a packet of fags, although the latter may last longer. There were also worries that men with penises that worked perfectly well would lie in order to try the drug. Which always seemed unlikely, given the embarrassment that surrounds impotence.

Maybe it's because I've worked in an impotence clinic (the politically correct and non-pejorative term is erectile dysfunction) and not on a ward full of incontinent old ladies (although I may become one some day), that the unfair distribution of Viagra makes me sad. Dobson's restrictions were not so much brave as strange. He decided, with the help of the Standing Medical Advisory Committee - a team of experts that advise ministers - to provide Viagra on the NHS for patients with erectile dysfunction due to multiple sclerosis, but not to those with liver failure. Patients who had extensive pelvic surgery for prostate cancer (destroying nerves involved in erections) qualified, but not those who'd had a stroke.

Erectile dysfunction due to psychological causes? Forget it.

As Dobson compassionately put it, 'impotence is neither life-threatening, nor does it cause physical pain'. And, he mercifully decreed, that 'in exceptional circumstances, where impotence is causing severe distress', a hospital specialist who'd never met the patient before could decide if the patient was upset enough to get it.

To ration a drug on the basis of cause, rather than effectiveness, isn't good rationing. At the launch, experts said Viagra could work better for less specific causes of erectile dysfunction (such as psychological ones).

Neither is it good rationing to ration one drug, while countless less effective treatments continue to be given. The only advantage of such restriction is that it's equally grossly unfair for everyone, unlike more insidious rationing - of infertility treatment, or chemo-therapy for breast cancer, which can be available in one postcode area but not a neighbouring one.

It is bad rationing not to cost the benefits of a therapy using some measure of quality of life. Certainly there are many patients with erectile dysfunction who could benefit from Viagra and can't afford it. But there are also many who assume they will not be eligible and won't attempt to get it. They will know that other therapies for erectile dysfunction, such as injecting drugs into the side of the penis, or inserting pellets into their urethras, or sticking their penis into a vacuum pump, are ungainly or painful.

It's a measure of how unexceptional it is to be severely distressed by erectile dysfunction that men suffer such treatments. Most men (unless they're too drunk to care) don't just shrug off a failure to sustain an erection.

I'm not saying that everyone who needs it should get Viagra, but it's not fair to discriminate by cause, as if some people don't deserve it because it's their fault they have erectile dysfunction.

But when you get a drug that works (in over 80% of cases) you should make sure that it's fairly distributed. If the Mail is right, the data will suggest this isn't the case.

In place of the Medical Advisory Committee, there is now a new body in England and Wales to advise on new technologies, including drugs, before they are introduced into the NHS. Called the National Institute of Clinical Excellence, it has the acronym Nice to live up to. It's widely thought that it will initiate the first real national rationing, by weighing up whether new drugs are better than available treatments and whether they are worth spending money on in an NHS that still needs to fund the nursing of incontinent old ladies.

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