The UK government last week issued draft guidance to doctors on when they could prescribe sildenafil citrate (Viagra) to patients on the NHS. Doctors’ representatives immediately rejected the government’s proposals as “cruel and unethical.”
Frank Dobson, secretary of state for health, said that GPs could prescribe Viagra and other drug treatments for impotence only to patients who have undergone prostatectomy or radical pelvic surgery, or have a spinal cord injury, diabetes, multiple sclerosis, or single gene neurological disease.
The minister says that NHS treatment may also be available “in a hospital setting subject to specialist assessment in those exceptional circumstances where impotence is causing severe distress.” Doctors will be advised to restrict their prescribing of treatment for impotence to one treatment a week. Patients not suffering from one of the named conditions would be able to get a private prescription. The pills cost about £6 each.
Mr Dobson pointed out that if Viagra were freely available the cost of treating impotence could increase 10-fold or more. He said that he wanted to keep spending to its current level—estimated to be between £10m ($16m) and £12m a year. Mr Dobson said, “We have to find a sensible balance between treating men with a distressing condition and protecting the resources of the NHS to deal with other patients—for example, with cancer, heart disease, and mental health problems.”
During the six week consultation period on the government’s proposals the BMA will countermand the recommendations of the secretary of state and advise GPs to prescribe the drug on the NHS where it is clinically indicated.
When the drug was licensed last summer, the Standing Medical Advisory Committee (SMAC) advised that doctors should not prescribe the drug other than “in exceptional circumstances” (19 September 1998, p 836). The committee set up a working party to prepare more detailed guidance, and reported to the government in November. It predicted that as an oral treatment Viagra was likely to be more acceptable than injections or mechanical devices and was cheaper.
It concluded that there was no medical reason why the drug should not be available on the NHS, nor why it should not be prescribed by GPs with referral to hospital specialists where appropriate. It also suggested that ministers should consider the priority given to all the methods of managing erectile dysfunction in the NHS relative to treatments for other conditions, but that any decision should take into account equity of access as well as availability of resources.
The BMA’s General Practitioners Committee took great exception to the proposals at its meeting last week. It saw them as unworkable and said they made a cruel and unethical distinction between acceptable and unacceptable forms of impotence. The committee believes that it is wrong to distinguish between patients according to the cause of their erectile dysfunction.
Members criticised the minister’s statement that “impotence is in itself neither life threatening, nor does it cause physical pain.” The chairman of the BMA council, Dr Ian Bogle, said that if those were the criteria for treatment “they exclude most of my life’s work.” Many patients would have to be referred to hospital when they could be treated by their GPs and this would increase consultants’ workload.
Dr John Canning, a GP in Middlesbrough, supported the government’s stance. He told the GPC that the profession had continually asked the government to make rationing decisions and Mr Dobson had now made an attempt to do so. There was a risk that GPs might raise expectations if they prescribed Viagra under the NHS and then had to stop if new regulations were introduced at the end of the consultation period.
The president of the Royal College of Physicians, Professor George Alberti, also said that the government’s decision was a clear indication of overt rationing, which the college supported. “What we have got here is a drug that could cost a lot of money,” he said, and he challenged critics to name the diseases which should be dropped from NHS treatment in order to pay for Viagra.
The chief executive of the NHS Confederation, Stephen Thornton, said, “These are landmark proposals from government, representing the first time that it has set clear eligibility criteria for a new drug on a national basis. This will ensure that we have a uniform approach around the country, avoiding the danger of postcode prescribing. We would support similar action from the government in respect of new drugs in the future, as resources must be managed in the NHS to protect other more pressing priorities.”
The King’s Fund also welcomed the consultation period. Angela Coulter, the fund’s director of policy and development, said, “This is the first time a government of any party has involved the public in a rationing debate.”
Pfizer, which makes Viagra, has accused the government of breaching one of the NHS’s principles, that medical treatment should be available to patients on the basis of clinical need. The company says that the conditions specified by Mr Dobson represent about 15%of those who could benefit clinically from Viagra and that the minister has discriminated against patients with heart and psychological problems (see pp273, 284, 338).
Figure.
GPs might raise patients’ hopes if they jump the gun on prescribing