The plummeting cost of sildenafil has prompted a change of heart at the Department of Health. As newly available generic versions of the drug reduce its cost by 90%, civil servants have launched a consultation on whether to widen access to all men with erectile dysfunction.
The move has been welcomed by GP experts, who say that it presents an opportunity to address a problem that causes considerable anxiety to patients and to identify men who may be at risk of cardiovascular problems.
But the plans will also have a considerable workload implication for GPs, with the DH expecting demand for sildenafil to double or even treble if the proposed change goes ahead.
An impact assessment predicts that GP costs will increase from £10.8m to £16.8m, with many patients currently being treated by specialists being transferred to primary care.
The consultation document says: ‘Widening NHS access will lead to greater costs elsewhere. There would be an additional burden on primary care, in particular for GPs, as each new patient requires an average 1.9 consultations per year, at a cost of £68.’
Existing DH guidelines restrict GPs to providing sildenafil prescriptions only to men with related long-term conditions, such as prostate cancer or diabetes. The only other option in many cases is either to refer patients who can demonstrate ‘significant distress’ to a specialist clinic, or offer a private prescription.
These restrictions have been in place since 1999, when Viagra was first prescribed on the NHS and there were concerns there would be massive demand for it. But the drug finally came off patent last June. A pack of sildenafil that cost £21.27 a year ago now costs the NHS just £1.45.
The DH is proposing GPs should now be allowed to prescribe sildenafil according to clinical need, although restrictions on the other treatments for erectile dysfunction – tadalafil, vardenafil and branded Viagra – would remain in place.
The overall costs to the NHS are expected to fall as a result of the drop in price and fewer specialist consultations, from around £144m to £111m a year.
A DH spokesperson says: ‘We hope that the change will encourage more men to visit their GP or pharmacist and in the process be more open about their health problems, particularly as men can often be reluctant to speak to their doctor.’
The proposal has been broadly welcomed by GP experts in men’s health, who agree it will offer significant benefits for patients.
Professor Mike Kirby, visiting professor at the University of Hertfordshire and a GP in Radlett, Hertfordshire, says he will be ‘delighted’ if the change is made and dismisses any concerns that it will be abused.
He says: ‘Eighty percent of men would like to be asked about sexual function but would not bring up the topic unless asked.
‘It also provides an opportunity to address lifestyle issues. Erectile dysfunction is a harbinger of underlying vascular disease in many men and an opportunity to address CVD risk factors and pre-diabetes, together with hypogonadism.’
Dr David Russell, prescribing lead at Darlington CCG and a GP in the town, also welcomes the change, but says that even wider access could benefit patients.
He says: ‘Patients with erectile dysfunction should be seen by a healthcare professional and be properly assessed.
‘I’m also aware that some patients will be too embarrassed to attend, so having therapies available in pharmacies might allow patients whose lives and relationships may otherwise be a misery the chance for help.’
Analysis: ‘This decision allows GPs to use their judgment’
I welcome the proposal to relax the criteria for provision of sildenafil in the NHS, as it allows GPs to use their judgment.
This is a highly effective treatment and improves enjoyment of life for many. The drug has few adverse effects, but the dilemma remains – does the NHS have a responsibility for things that lie at the borderline of medical care and recreation?
A rapid move to over-the-counter provision of generic sildenafil might make sense and reduce the onus on the GP to restrict access to an effective drug within the NHS.
The responsibility would then lie with the patient to use it sensibly and safely. A lot of patients get the drug covertly via online pharmacies already, and this might be a better, more transparent option.
Dr Martin Duerden is RCGP clinical adviser on prescribing and a GP in Conwy, Wales