In a message dated 05/08/98 10:46:49 GMT, Julian wrote:

<<  My only intention in
 stating medical need was to exclude recreational use. >>
But how will you do this? If someone states they are impotent, you have to
take them at their word. You won't stop people who want to use the drug out of
curiosity and you won't stop those who want to set up a lucrative black market
in the stuff. If Viagra is as effective as it's made out to be, people will
stop at nothing to get it and make money out of it.
Those who think that going on a training course will somehow equip them to
decide who is genuine and who isn't, are naive in the extreme.


<<Firstly your post suggests that capacity to work should influence the
treatment a patient would receive.  Do you really mean this?  Would you
fail to put back the severed arm of a 55 year old otherwise fit divorced
man U/E for 10 years who will probably never work again?>>

Ability to support one's family should certainly in my view be a factor that
is taken into consideration when deciding on who should be treated as a
priority, yes. In fact when trying to expedite someone's joint replacement,  I
use this as a lever to gain a patient a place on the priority waiting list. To
use your example, the loss of an arm at any age is a disaster so no, I would
support re-implanting the arm of this patient unemployed or not.

<<Secondly your post tries to compare the priority of impotence treatment
with a few issues which you obviously consider at the top of the NHS
priority list.  This is not the point.  To exclude Viagra on this basis you
have to show that it is less important than the lowest priority treatment
that the NHS does give. >>
I don't agree. Viagra may not be less important than the lowest priority
treatment that the NHS  offers. But we have to have sufficient funds available
to treat the high priority issues that I instanced. Any surfeit of funds
afterwards can be used for lower priority treatments. I did not say anywhere
that Viagra should be lower down than the lowest priority NHS treatment.

<<If you have any 60 year old impotent arthritics try
asking New hip and no Viagra, cheap arthroplasty to cure pain and Viagra
for life? >>
Poor example, because the difference between having ,say, an Austin Moore
prosthesis and a THR with a Charnley would not give you enough money for a
lifetime's supply of Viagra. If the choice was between a Charnley hip and a
lifetime's supply of Viagra, I know what my osteoarthritic, impotent patients
would choose. But  you raise an interesting point.

<<I think we agree that the NHS cannot afford everything that patients want
or we would wish to offer.  Once we establish a way of setting priorities
we can draw a line.>>

I agree totally and I'm all for being honest with patients. At the end of the
day if patients are fully informed about the state of the NHS, it's lack of
funds and the increasing dichotomy between what medicine can do for patients
and what the NHS can afford.......if they understand all that and still think
Viagra should be available on the NHS then I'll be happy to prescribe it. It
would be interesting to see how a large random sample of patients would
prioritise Viagra, if anybody knows of a study, I'd be interested in seeing
it.

Best wishes

Jeremy Sager
GP
Leeds


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