Whatever happened to Viagra? Yes, I know it is now being prescribed, hopefully only under the aegis of HSC1999/115, and I hope that everyone is aware of the need for the prescriber to add the magic letters "SLS" to the prescription, otherwise it will be disallowed by the Prescription Pricing Authority. Disallowed prescriptions are routinely returned to the health authority by the PPA; my box file is bulging with prescriptions for Viagra and the other treatments for erectile dysfunction for which payment has been with-held. If my health authority is typical, the National Health Service must have saved an absolute packet on treatments for this condition in the past few months at the expense of contractors, both pharmacists and dispensing doctors.
My question relates to the dearth of Viagra stories in the media, on the internet and in general conversation. I have not heard a new Viagra joke for some time and even the old ones seem to have died down. There was a rather demure article in the Times late last year which discussed how middle-aged and elderly women were coping with their husbands' new-found, Viagra-turbocharged randiness, but that is about all. Now that the Department of Health, through its Health Service Circular, has given the official line on who is eligible to receive the drug on an NHS prescription, most people seem to have accepted it.
One part of my work as a health authority pharmaceutical adviser consists of answering telephone inquiries from the general public. These are invariably interesting, sometimes very time consuming, but usually pleasant. Patients are often very surprised to find that, on contacting the health authority, they can talk to a pharmacist about problems with treatments and have usually been most grateful for the time that I have given them. The topics covered have been wide-ranging and often concern issues such as the number of prescription charges payable on products such as hormone replacement therapy treatments, or about entitlement to exemption from prescription charges. There have been some interesting discussions - occasionally rather heated but always well-mannered - about beta-interferon for multiple sclerosis. A number of women, and one or two men, have wished to talk about Xenical for weight loss and about its availability on prescription. One has to have a measure of sympathy with the plight of some patients - or does that simply mean that I am a sucker for a sob story? I do not think so. Others have asked about the side effects of drugs outlined in the patient pack leaflets. Why they do not ask their community pharmacist I do not know. Perhaps they think they will get a better answer from the health authority. Someone should do some research on this.
The only exception to the generally civilised discussions with patients has been over Viagra. The calls started before the drug was licensed and reached a crescendo in the few weeks immediately after it was marketed. The calls seemed to have been fuelled by the media, particularly after a morning television chat show advised viewers to pester their local health authority to make the drug available immediately and, of course, free.
Most of the callers were little short of abusive. One man opened his call with something like, "I want to know why you men in grey suits are stopping us getting something we want". One young woman, who wanted a child but whose fiancée suffered from erectile dysfunction, screamed hysterically at me and used some very unladylike language before slamming down the telephone. At least one other man informed me that he had fought for this country, and as a result was entitled . . . etc, etc. My colleagues in the office always knew when I had had yet another "Viagra" discussion from my haggard appearance and occasional (just occasional) use of some slightly ungentlemanly language once the caller had rung off.
Why, I ask myself, did the subject of Viagra cause such extreme angst among the general public? Did this happen in other countries, or was it peculiar to the British? Could it be due to our traditionally ambivalent attitude to sex, or was there another reason? One possibility may have been that "Viagra" was the first really clear discussion that we have had in this country on the issue of rationing of health care. It must be patently obvious to anyone that, with finite resources and a potentially infinite level of demand, something somewhere has to give. Either we as a society pay much more for our medical treatment or we purchase less treatment. There is a desperate need for a true debate on rationing in which the public can be involved.
Unfortunately, an individual person's priority is usually his or her own view of what should be provided, regardless of other competing interests and the overall benefits to society. For example, a nurse who specialised in health care of the elderly might want more care for the old, or a paediatrician may want more care for children. In other spheres of public expenditure but outside of the NHS, teachers, for instance, may feel that more should be spent on school books, while Royal Air Force officers might consider that more Spitfires (or whatever they fly in today) were needed. However, there will always be a finite limit to the amount of public money available. This is particularly so in a political atmosphere in which no politician will offer to raise taxation and some actively promote the concept of lower taxes.
Some kind of rationing in health care provision, regardless of how it is dressed up and "spun" by the politicians, is therefore inevitable. This might, in fact, be a good thing. Incited, I suspect, by the media, people tend to think of "rationing" of health care expenditure (note that I refer to rationing of expenditure, not rationing of care) as being bad and designed to prevent patients from having access to necessary treatment. Properly organised, however, rationing could do the opposite. Whatever the current generation of revisionist historians may say, wartime rationing ensured that everyone received a fair(ish) share of essential foodstuffs and other items such as clothing.
What impact might the rationing of health care expenditure have on pharmacy? One very real possibility is that prescription numbers could fall, bringing with it a reduction in community pharmacists' remuneration, if remuneration remains on the same basis as now. However, the various new roles proposed for community pharmacy will need to be funded, and we may have to accept that the funding of these might be at the expense of that for the traditional dispensing role.
We have heard people in the profession saying "no new roles without new funding" but this may be unrealistic. Anyway, would we really be comfortable with increased funding for pharmacists' activities at the expense of, say, services for children or for cancer sufferers? I, for one, would not, and I suspect that many other pharmacists would not be either.
I firmly believe that some kind of rationing of health care expenditure is inevitable, regardless of politicians' promises. The only questions are what kind of rationing and how it will be achieved. Head-in-the-sand attitudes, whether on the part of professionals and their organisations or of the political fraternity, will only delay the inevitable and may well result in less than satisfactory solutions to the intractable problem of too little money and too much demand on it. The pharmacy profession might, therefore, and before too long, have to face up to some hard facts, as well as hard choices.
John Wilson is a pharmacist based in Arnold, Nottinghamshire, who has retired and now works part-time (e-mail john@ginadog.demon.co.uk)