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Treating erectile dysfunction in primary care

The distress of erectile dysfunction can be alleviated by a holistic service based in primary care, writes Dr Mike Callander

The distress of erectile dysfunction can be alleviated by a holistic service based in primary care, writes Dr Mike Callander

I have been a provider of a primary care erectile dysfunction service for many years and believe this model offers practice-based commissioners a cost-effective way to successfully treat the condition, alleviate patients'distress, and identify comorbidities such as cardiovascular disease.

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Originally I provided the service on a cost-per-case basis under fundholding for any GP and I was also involved in the training of GPs throughout the north-west of England.

Later, after fundholding had been scrapped by Labour, I became an ED service provider for my PCT. The back ground to the service I provide is the evolving story of ED. Until 1985 there was almost no effective treatment for ED. It was considered to be largely psychogenic in aetiology and psychotherapy was the only avenue of treatment and usually unsuccessful.

However, a one-hour lecture given by British physiologist Giles Brindley to a urology meeting in Las Vegas in 1983 changed the therapeutic paradigm overnight, as he demonstrated live to an audience the effect of a papaverine injection self-administered beforehand. Intracavernosal therapy became the new standard of care, the physiology and pharmacology of the erectile process became understood, and new drugs were developed, including PDE5 inhibitors such as sidenafil.

Researchers have predicted that worldwide prevalence of ED will double from 152 million men in 1995 to 322 million by 2025. It is a condition that increases with age and also is a warning sign of coronary artery disease (with ED symptoms coming 39 months on average before CAD symptoms in about two-thirds of men, according to one study). Coronary heart disease is still a leading cause of death in men and women in the UK.

BARRIERS TO EFFECTIVE CARE

I believe that women and men's sexual health care is a fundamental and basic human right. Men with ED often experience severe distress, which significantly disrupts their normal social and occupational activities and has a marked effect on mood, behaviour and interpersonal relationships.

In 1999, the Department of Health issued guidelines (known as ‘schedule 2') that restricted NHS prescribing of impotence drugs to men with certain medical conditions, and recommended that patients whose ED was causing them severe distress should be seen by specialist services.

These guidelines were in effect barriers to care. Few NHS hospital trusts provide a service for assessing patients with severe distress, many patients fall outside the list of approved conditions and lack the financial means to pay for treatment, and long-term prescribing for each patient from an NHS hospital setting is impractical.

In 2001 I approached my PCT, (then Trafford North, which merged with another last October to become Trafford PCT) with the idea of providing an ED service, based on my previous work with a neighbouring PCT.

I used information on comorbidities, patient distress attributable to ED and lifestyle interventions – for example, smoking cessation – to persuade the trust to back the service.

The service was up and running within six months. It did not need accreditation by any professional body, but I did have the backing of a local urologist who was at the time providing a secondary care andrology service. It was necessary to recruit a clinic manager and a nurse, which I was able to do from my existing staff.

I was also able to make use of our premises and equipment. The only additional equipment required was patient information leaflets and medication for test doses (intracavernosal injections, intraurethral pellets and vacuum pump devices for loan). All treatments are now available on prescription under schedule 2.
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Based on my previous experience, I requested referring GPs to carry out investigations (fasting glucose or glycated haemoglobin; fasting lipid profile; early morning testosterone; and PSA if aged over 50), the results of which would be available when I saw the patient to enable me to make an accurate assessment and prescribe appropriate treatment. The service did not need pump-priming, apart from quarterly payments in advance.

Additionally a dedicated ED prescribing budget was arranged through medicines management at the PCT, which has transformed the service and allows treatment for all patients on the NHS.

In the last financial year the service cost the PCT £42, 250, plus the ED prescribing budget of £4, 000. The service takes referrals from all 75 GPs in the PCT. From January 2006 to January 2007 we received 91 new referrals and had 390 follow-ups. We compete favourably with the Payment by Results tariff of £160 for a first urology appointment and £80 for a follow-up.

LOW RELIANCE ON SECONDARY CARE

Initially the patient has a 45-minute appointment with a practice nurse (which I specially trained on dealing with ED patients), followed by a 30-minute appointment with me within one or two weeks. This is followed by a further 15-minute appointment with the nurse, after which 80% of patients are successfully treated.

We discharge patients who qualify for treatment under schedule 2, except those patients who qualify for treatment because of severe distress. We continue to prescribe for them and review them every six months. The waiting list for the first appointment is one month.

As part of our service we take on board the holistic assessment of patients, do our utmost to encourage smokers to quit, and refer back to their GP any other symptoms or recommendations for treatment. For example, we picked up raised lipids in a man recently referred to me, so I wrote to a specialist seeking advice, who recommended treating him aggressively for hyperlipidaemia.

There is no typical patient. Still, we are able to address all our patients'needs and refer on to secondary care rarely for surgical management (penile implants) and

psychosexual treatment. I am 18 months into my second threeyear contract with the PCT and the future of the service is secure because of the high level of patient satisfaction and the unqualified support of my GP colleagues.

Savings come about as a result of early diagnosis of comorbidities, smoking cessation and patient/partner satisfaction. On a distress scale of 1-10, with 10 being the highest, we see patients'levels fall from an average of 7 to 3 or below.

BUILDING YOUR CASE FOR A SERVICE

Practice-based commissioners looking to start an ED service from scratch need to draw up a high-level business case that includes:

• a rationale for disinvestment in current secondary care provision and reinvestment in a primary care PBC service

• how the primary care-based ED service will improve on current arrangements

• current demand levels for the service

• cost comparison of patients currently treated in secondary care against the cost of treatment within a primary care ED service

• a demonstration of cost savings that can be realised through commissioning the ED service within a primary care setting through PBC.

I have developed software, in conjunction with Pfizer, to capture real-time data on comorbidities and 10-year cardiac risk assessment. It also provides real-time data on severe distress before and after successful treatment.

This is powerful data in persuading PCTs to commission an ED service and we are in the final stages of going live with a national website to which information can be uploaded and viewed in real time for the whole of the UK by members of the Primary Care Sexual Dysfunction Society.

It is certainly a tool that I wish I had had available when originally commissioning my ED service.

Dr Mike Callander spends 30 minutes with ED patients referred to him Dr Mike Callander spends 30 minutes with ED patients referred to him

We take on board holistic assessment of patients, and refer back to their GP on any other symptoms.

60 second summary Comorbid 2

We take on board holistic assessment of patients, and refer back to their GP any other symptoms.

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