When seeing one of your partner’s patients, you discover that the colleague normally gives him an NHS prescription for Viagra, even though he’s not eligible. How should this situation be managed?
Explain what you’re doing, but don’t blame your partner
The NHS is an incredibly complex system, and one that most patients (and indeed some doctors) don’t fully understand. The specific rules for the prescription of Viagra and other erectile dysfunction drugs were set by the Department of Health in a way that many have felt was unfair and iniquitous and has yet to be applied to any other areas of treatment in the same way.
This patient is certainly not the only one to have felt aggrieved that their treatment was dealt with differently by NHS regulations than other treatments. However, whatever our individual opinions and those of our patients, these are the regulations and we do not have latitude to reinterpret them. This is to ensure that treatment and care within the NHS is provided on an equitable and fair basis to all patients.
I would apologise for the error that appeared to have been made but explain that we could not continue to prescribe on an NHS prescription now that it had been identified. Explanation of the relevant regulations may help and these are quite clear in the BNF, but I would endeavour not to criticise my partner.
We have no way of knowing what went on within the initial consultation which may have been some considerable time ago, with the prescription simply being repeated without re-examining the indication, etc.
While wanting to avoid confrontation with the patient, the guidelines are clear, and a complaint on this matter would be unlikely to be upheld.
Dr Richard van Mellaerts is a GP in Kingston and a GPC member.
Offer an NHS script to pre-empt a complaint
I would be first to admit I have been put into this situation by GP colleagues, and have put colleagues in same situation in the past too.
According to the BNF, erectile dysfunction drugs can only be prescribed on the NHS (endorsed with “SLS”) in certain circumstances.
I might speculate why the partner offered NHS prescriptions: perhaps it was a stressful day and they did not have the energy to explain or a way of offering compromise in context of a difficult consultation or since generic sildenafil has become available (£3.10 for 8 tablet pack according to BNF), cost might not be an issue.
Whatever the reason, it might appear difficult for anyone to back down.
I would check if he met NHS prescription criteria and if anyone has mentioned this before. To pre-empt complaints (practice reputation matters these days), I would offer the same to the patient while maintaining that in usual circumstances I would offer a private prescription. I would offer to find out the rationale with the partner and apologise if that had been an oversight.
I would discuss with the partner and get some agreement for future prescriptions. If further issues should be on the NHS, I would suggest it should be on repeat prescription at agreed interval and quantity, with endorsement by that partner clearly stated to pre-empt situations like this in the future.
This may also be a good opportunity for the clinical team to discuss management of prescriptions outside current guidelines.
Dr Richard Ma is a GP in Islington, North London.
Consider dealing with the patient’s dissatisfaction as a complaint
The Department of Health’s drug tariff for England and Wales lists the purposes for which a doctor can prescribe treatments for erectile dysfunction on the NHS.1
These include for men with multiple sclerosis, Parkinson’s disease, polio, prostate cancer and pelvic floor injury, for example. There is separate guidance which applies in Northern Ireland and Scotland.2,3
If you feel that the patient doesn’t fall into any of the categories that might make him eligible for an NHS prescription, you should explain this to him and discuss any alternative treatments, including the option of a second opinion.
You should consider dealing with the patient’s dissatisfaction as a complaint, whether or not he says he is going to complain. When investigating the issue, you will need to involve your colleague who was previously issuing NHS prescriptions. There may, for example, be a simple difference in clinical opinion between you and your colleague to account for the differences in your prescribing decisions.
As a result of investigating the complaint, you may identify a need for further training on prescribing within the drug tariff and the need to review and update any relevant practice policy.
Dr Richenda Tisdale is a medico-legal adviser at the Medical Defence Union.
1 Prescription Pricing Authority. Drug Tariff. December 2013. http://www.ppa.org.uk/ppa/edt_intro.htm
2 Northern Ireland Regional Group on Specialist Medicines. Red Amber List. http://www.ipnsm.hscni.net
3 ISD Scotland. Scottish Drug Tariff. February 2013, http://www.isdscotland.org/Health-Topics/Prescribing-and-Medicines/Scottish-Drug-Tariff