Health CommitteeWritten evidence from Men’s Health Expert Policy Group (LTC 80)

The Men’s Health Expert Policy Group is a multi-disciplinary group of leading primary and secondary care clinicians, charities and advocacy groups with specialist interests in men’s health, endocrinology, cardiovascular disease, and sexual health.

The Group would like to take this opportunity to respond to the Health Select Committee’s inquiry examining how the NHS in England can improve the care for people with long-term conditions, particularly people suffering from diabetes. There is strong evidence of the links between common men’s health problems, such as erectile dysfunction (ED) and testosterone deficiency syndrome (TDS), and more serious long-term conditions such as type-2 diabetes. It is important therefore that the Committee considers these as part of its inquiry. Our recommendations to the Committee are in bold.

As the Committee will be aware, ED is the consistent inability to get or maintain an erection during sexual intercourse and is thought to affect more than one in ten men.1 On the other hand, TDS is estimated to affect one in ten men between the ages of 20 and 792 and is a condition where the body does not produce enough of the hormone testosterone. Although both conditions can be treated, there is significant variation in the quality of services being provided and commissioned for these conditions in England,3 which can results in missed diagnosis and failure to treat.

In March 2013, the Department of Health published its sexual health policy document, A Framework for Sexual Health Improvement in England, and the accompanying commissioning guidance for local authorities, Commissioning Sexual Health Services and Interventions: Best Practice Guidance for Local Authorities.

The Framework recognises that erectile dysfunction (ED) is “a marker for underlying CVD [cardiovascular disease] and health professionals should be alert to this issue, which provides an early opportunity to treat the risks of CVD as well as addressing erectile dysfunction” . The Group welcomes this inclusion within the Framework as an acknowledgement of the growing body of evidence to demonstrate that common men’s health conditions can be indicators of an elevated risk of developing more serious cardiovascular conditions—including type-2 diabetes

However, despite recognition of this, both the Framework and the subsequent guidance fail to provide clarity about where responsibilities lie for the commissioning of men’s health services. This is with the exception of vasectomy. The documents also provide no information about how the commissioning of specific men’s health services, including for managing ED and TDS, will be shared between local authorities, clinical commissioning groups (CCGs) and NHS England.

Given the linkages between men’s health conditions and more serious long-term conditions, the Committee should recommend that the Department of Health, with NHS England and Public Health England, provide further clarity about where responsibility for men’s health sits to ensure patients have a joined-up experience of care and promote earlier diagnosis.

Early complications of type 2 diabetes include ED and TDS, and can often be identified before a man is given a diagnosis of the condition. For example, by the time people with type 2 diabetes are diagnosed, it is estimated that half are already showing signs of complications of their disease4 which, for men, could include erectile problems. Furthermore, it has been estimated that complications may appear five to six years before they have a diagnosis of the underlying disease.5

The Committee should recommend that government, the NHS and healthcare professionals consider ED and TDS as an important warning sign for diabetes before more serious complications arise. Furthermore, it is important that GPs ask men with diabetes about ED as this is a serious consequence of the condition and can also be a symptom of TDS.

The National Institute for Health and Care Excellence (NICE) clinical guideline for the management of type 2 diabetes identifies ED as a side-effect of diabetes in men.6 The guideline outlines that clinicians should:

Review the issue of ED with men annually.

Provide assessment and education for men with ED to address contributory factors and treatment options.

Offer a phosphodiesterase-5 inhibitor (choosing the drug with the lowest acquisition cost), in the absence of contraindications if ED is a problem.

Following discussion, refer to a service offering other medical, surgical, or psychological management of ED if phosphodiesterase-5 inhibitors have been unsuccessful.

It is important that healthcare professionals follow these guidelines and local health bodies monitor its implementation.

Building on this guidance, the Group has welcomed the inclusion of two new indicators to the Quality Outcomes Framework for 2013–14 of relevance to ED and diabetes.7 These indicators are aimed at incentivising GPs to ask male patients with diabetes about ED and the treatment options for ED. The inclusion of these indicators represents an important step in ensuring men’s health issues are appropriately prioritised in primary care.

However, with one in five GPs admitting that they are not comfortable talking to men about sexual health issues,8 further support needs to be made available to ensure primary care practitioners have the training and resources to discuss these important issues, and that men are having equal access to the care and support they need. The Committee should recommend that Public Health England work with the Royal College of General Practitioners to take this agenda forward as part of the wider Making every contact count initiative.

Furthermore, the Cardiovascular Disease Outcomes Strategy commits NHS England to work with stakeholders “to identify how to incentivise and support primary care consistently to provide good management of people with or at risk of CVD”, including from relevant QOF indicators.9 The Group supports this commitment. The Committee should recommend that, as part of this work, NHS England looks at how the QOF indicators for ED and diabetes are being implemented and identifies areas where these can be improved upon.

Members of the Men’s Health Expert Policy Group

Dr Graham Jackson, Consultant Cardiologist, Guy’s and St Thomas’ Hospital; Chair, Sexual Advice Association

Professor Hugh Jones, Hon. Professor of Andrology and Consultant Endocrinologist, Barnsley Hospital

Colin Penning, External Affairs Officer, Men’s Health Forum

Gavin Terry, Policy Manager, Diabetes UK

Dr David Edwards, General Practitioner, Chipping Norton, Oxfordshire; President, British Society for Sexual Medicine

Bharat Patel, Chair, National Pharmacy Association

Jean Arrowsmith, Joint Chair, Coventry Men’s Health Forum

9 May 2013