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Compulsive inhaler freak

Phil wishes his heartsink would stick with one inhaler – or vanish in a puff of smoke

'I'm sorry but Vlad is here again,' says the receptionist. 'I've had to fit him in as an extra with you.'

'Sorry but I'm not feeling very well,' I try, without much hope.

'Neither is he,' she returns.

Vlad The Inhaler is an unusual heartsink patient. I'm not sure there is a proper category for him yet. He has asthma; not bad asthma by any quantitative measurement (he has never been admitted to hospital with it), but he presents the roughest asthma management dilemma in our practice.

Vlad has a unique attitude to his ailment. He regards inhalers in the same way that twitchers regard rare warblers. Like birdwatchers who have to tick off arcane species in their notebooks, Vlad The Inhaler has to have a gasp on every respiratory device on the market. I don't know how many species of birds there are in the UK, but I do know there are at least a couple of hundred different inhalers available on prescription, once you take all the varied delivery devices into account.

Vlad has a profound psychological need to try them all. Somewhere deep in his soul he harbours the belief that one of them will miraculously provide him with both relief from that minor irritating cough, and give him the ability to smoke as many cigarettes as he wants.

He uses his inhalers as a theatrical device. I don't venture into our waiting room if I can help it (I've read about the Black Hole Of Calcutta and that's as close as I care to get) but sources tell me Vlad is the focus of attention whenever he is there. Every 30 seconds or so he will leap up and draw several juddering gasps on the inhaler du jour, fanning his face and wheezing. Then he wanders outside for a fag.

I assume Vlad is a keen subscriber to What Inhaler? magazine, as he is always on the doorstep when a sexy new device is on the market. As an expert manipulator of locums and registrars, he usually gets what he comes for.

I had never previously considered this as a problem. 'It's just a bunch of puffers,' I might have rationalised, but our new computer system shows the price as we complete the prescription, and I must admit to being shocked at what we are giving out. Some of these things cost 35 clams a punt, and having once observed Vlad in a pub, taking alternate puffs from his fag and his state-of-the-art delivery device, I calculated he had spent 20 quid of our prescribing budget in just two pints.

Practice-based commissioning alters the playing field somewhat.

I have to manage our prescribing budget now, and Vlad is on thin ice. Previously, I could just about live with the fact that a couple of thousand pounds a year of taxpayers' money was spent on making Vlad's smoking experience more comfortable.

Now it's my money, and I don't like it so much. If he misses just one appointment, he is off the list. And one of you lot will have to take him on. Don't hold your breath.

Dr Phil Peverley is a GP in Sunderland and PPA Columnist of the Year 2006

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