New NHS post-code lottery in erections

As a man with reduced sexual function following prostate surgery challenges a local decision to halve the prescription of drugs that help erections, malehealth examines the implications.

The south central priorities committee which deals with PCTs in Milton Keynes, Oxfordshire, Berkshire East, Berkshire West and Buckinghamshire has recommended that some 33,000 men entitled to NHS prescriptions for drugs like Viagra, Levitra and Cialis (so-called PDE-5 inhibitors) are limited to just two a month. The result is effectively a post-code lottery in erections.

Simon Lord, who lives in the area and was just 50 when he was diagnosed with prostate cancer, has used freedom of information legislation to find out more about prostate treatment in his area. ‘I think they’ve cut erectile dysfunction (ED) treatments for men like me because they think we won’t complain. Well, they're wrong about that.

'Before they took this moribund decision, there was no proper review and evidence gathering. In my view, the committee don’t even have a mandate to make these sorts of recommendation. Indeed, they wouldn’t even tell me how they’d arrived at the decision. My GP has decided to follow these arbitrary guidelines with the result that my prescribed ED drug allowance has gone down by 75%.’

NHS prescriptions for PDE-5 inhibitors are already very limited. They are only available for men with diabetes, multiple sclerosis, Parkinson’s disease, polio, prostate cancer, a severe pelvic or spinal injury, spina bifida and certain genetic conditions, such as Huntington's disease. They may also be available after pelvic surgery, surgical removal of the prostate gland, dialysis for kidney failure or a kidney transplant. When these drugs first appeared on the market in the late 90s there was concern that their prescription could bankrupt the NHS and as a result patients have usually been limited to four tablets a month.

The missing evidence

The south central priorities committee discussed reducing this allowance at their February 2011 meeting. According to the minutes, members were told that 'the current spend on oral drug treatments [for ED] across south central amounts to about £4.4 million'. The committee said this was 'unaffordable in the current climate'.

However, they also 'acknowledged that the treatments worked but could not establish the impact of this on quality of life due to lack of published evidence'. At their March meeting, they heard evidence on quality of life.

A report was presented to the committee by Solutions for Public Health, a not-for-profit NHS public health organisation that works with decision makers to improve health and, in their own words, 'reduce health inequalities'. The report said: 'There is some evidence from randomized controlled trials for an association between erectile dysfunction and a negative impact on sexual quality of life. The association with overall quality of life is less clear.' However, the report admitted that 'no systematic reviews on quality of life and erectile dysfunction were identified'. Is this good enough for such a decision?

GP's views ignored

The views of men who take these drugs were not sought although Dr David Edwards, a GP with a special interest in male sexual function, was listened to for a few minutes at the February meeting. He questions the committee's decision.

'I'm very worried it will drive men onto the counterfeit market,' he said. 'I've had several patients come to me with fake tablets which are at best ineffective and at worst dangerous. One man had red "Viagra" that he'd bought in a pub. I've no idea what it was but it wasn't Viagra. If patients are bypassing us by going online, doctors are also unable to diagnose other possible causes of ED like diabetes or heart problems.'

Edwards went on: 'I explained to the priorities committee how to save money in this area but they chose to ignore it.' He pointed out that since most patients are not on the highest dose, men could simply be prescribed a larger dose and cut the tablets in halves or quarters. 'Pharmacists sell tablet cutters for this very purpose,' he said. 'Although it can easily be done with a chopping board and stanley knife. This sort of thing is standard practice with drugs like amitryptiline and aspirin. I explained it all to them but I think it was a done deal - they'd made up their minds before the meeting.'

Edwards also questioned the legality of PDE-5 inhibitor rationing. 'If you have erection problems because of diabetes you're entitled to an NHS preciption. If you have ED because of high blood pressure, you have to pay the full price. I think if someone took that sort of unfairness to the European Court, the NHS would be found wanting. I simply don't believe they've looked at the real costs of a decision like this. ED destroys relationships. What's the cost of that to the whole family?'

Arbitrary limits also reduce the possibility in some men for penile rehabilitation. In order to restore erectile capacity and prevent atrophy, keeping a good flow of blood to the penis is essential. For men who have had a radical prostectomy, Edwards often prescribes a daily PDE-5 inhibitor and a vacuum pump to facilitate this. But, he stresses, 'this need to be started as soon as possible after surgery. With it, some men can get some function back which reduces the long-term need for PDE-5 inhibitors anyway.'

Younger men are increasingly being diagnosed with prostate cancer but this is not the only condition for which the treatment can leave men with erection problems. Different men are affected in different ways by different types of interventions, surgery and treatments such as radiotherapy. Lord has condemned the ‘one size fits all’ approach and called on the committee to treat men as individuals and look at the evidence.

NHS-funded erections for life?

But how far does the NHS's obligation to deal with the side-effects of treatment, especially life-saving treatment, go?

John Walker, right, who has written about his own experience of prostate cancer diagnosis in his 40s on malehealth, says it’s not as simple as it might at first appear. 'How far should the responsibility of the state in its various forms extend, especially in the middle of what many economists seem to believe is financial meltdown? The pressure to cut costs is substantial.

'The NHS has presumably funded the operation that has removed the cancer. The possibility of the loss or reduction of sexual function was presumably discussed pre-op. Something to (attempt to) restore things to "normality" is given as part of the recovery process but I don't believe the PCT are under any obligation to continue to provide the drugs ad infinitum.

'The number of sexual encounters one has is personal whatever age you. Sexual potency generally diminishes as one gets older (sadly). And some men will recover their function post prostate surgery.' John concludes: 'Is this really an unreasonable expense for most men? Tesco sell Viagra at £50 or so for 8 tablets. I advise getting a ClubCard.'

What do you think? PDE-5 inhibitors improve erectile capacity but there are plenty of things that can done in the bedroom short of penetration. Perhaps men just need to learn to love other parts of their and their partner's bodies a little bit more.

• Read the story of the original decision: Should men be limited to two erections a month?
• John Walker: I told my GP, I respected his decision, but if I'd followed his advice I'd probably be dead
• John and Christine Walker: Gone missing - our sex life