Sildenafil is an interesting topic because it brings together a number of issues for health workers. Unlike many new medications it is very effective and has few side effects. Like many new medications it is expensive. Unlike most new medications the existing alternatives are not very effective, some indeed appear Medieval in their approach.

Like many new treatments sildenafil can cross the boundary between health care and social well-being and even leisure activities. It is and will almost certainly be increasingly on the black market.

Firstly effectiveness. Figure 1, taken from Bandolier, July 1998, shows that in large randomised trials the treatment is very effective (Number Needed to Treat of 2 i.e. half of the people tested received benefit). There was also a noticeable dose-response effect. Major side effects in these trials were minimal. It is contraindicated for men taking nitrates for heart disease.

The trials used a useful questionnaire method of assessing erectile dysfunction. The mean age of the men in the studies was 58. They had a wide range of causes of erectile dysfunction. There is even some unpublished evidence that it helps men with spinal injuries.

We obviously need to welcome this effective new drug which will relieve considerable suffering. Personally I feel that the simplest and boldest way to prevent its misuse would be to make it available over the counter.

I fear that we will instead draw up a Byzantine list of requirements for people to get it by prescription in order to limit the cost to the NHS - a form of back door rationing.

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The Welsh Green Paper was published last month. It tackles issues related to the determinants of health. The subject is hardly new; it was proposed in its modern form by Lalonde in 1974¹. In this interest centres around the small contribution, which the health services make to good health, as distinct from the treatment of disease, compared with the effects of social and physical environment, family history and lifestyle factors. The government has rediscovered that the NHS spends over 90% of its money treating disease, not in improving health.

The green paper is short on evidence about how to use this information The close relationships between, for instance, unemployment and the use of health services does not lead to an obvious conclusion about how to reverse this, except by offering more employment to people. The NHS certainly does employ many people and the sighting of some hospitals within Bro Taf in poor areas probably had this in mind, but not everyone can work for the NHS.

Research has suggested that the effective way to reduce inequalities in health is to concentrate on primary care services. Paine made a strong point: "Such actions are beginning to break through the carapace ... the hospital have too often surrounded themselves with in the past'.

For example the North Central Bronx Hospital in New York faced problems of large numbers of deprived people. In response it phased out specialist clinics and replaced them by five primary health care teams responsible for all of the care for a particular group of families in the district.

Dr Halfdan Mahler, a previous Director General of the World Health Organisation (WHO), has suggested that it is the job of people in public health medicine, ‘the heirs of Chadwick’ to become social reformers. Their first job is to free the public from these mysteries, by explaining them in detail and secondly to point out the importance of other, more politically sensitive social conditions on the health of groups and individuals.

This is a very political agenda, fitting well with the new changes, including Local Health Groups within the NHS, as long as these groups are truly open to public scrutiny and suggestion.

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In an article in the Lancet (1997; 349:126-8), Alan Maynard attacked the proponents of EBM for "taking us back to the days...when treatment decisions were dominated by clinicians and the individual patient ethic of effectiveness.. "

Tony Lipman a GP in Newcastle has suggested the flaws in this argument. ‘Alan Maynard doesn't take into account that individual clinical judgement is as important as knowing how to process evidence.

‘...we don't just mechanically put everyone with atrial fibrillation on warfarin - we try to assess not only the clinical benefit (expressed as the number needed to treat to prevent stroke, for example) and the harms (risk of bleeding etc) but also whether the patient wants to have regular checks, how they feel about taking the tablets etc.

EBM simply makes the clinical information upon which to base these judgements and choices explicit. It does not replace the obligation always to take into account social, psychological, cultural and economic factors.

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