The debate about the availability of Viagra on the NHS have implications much wider than the treatment of impotence alone. Health secretary Frank Dobson should be congratulated on taking the politically risky step of offering a central policy decision on what the NHS can be expected, or is capable of providing. One shudders to think of the mess that would have been created if, once again, politicians had opted out of making a difficult decision, and left it to individual health authorities to 'ration' the availability of Viagra 'according to postcode'.

Unfortunately, the same boldness and clarity of thinking is not apparent in the way the NHS allows access to a range of existing treatments, including fertility, osteopathy and Alzheimer's drugs. You may or may not have access to these treatments if you live on one side of the street as opposed to the other - if it falls under a neighbouring HA. I hope this is the start of a new trend in elected politicians taking responsibility for decisions about what core expectations we can have of our NHS, wherever we live.

On the specific question of Viagra, I believe that Mr Dobson's decision at least to delay access is justified. Of course, sexual fulfilment is a vital part of most of our well-being. However, a range of effective, if less popular treatments for male impotence are readily available and far less costly than Viagra. Surely it is right to buy a little time to consider exactly how Viagra might complement existing NHS treatment of impotence (perhaps as an option to be tried when other existing methods have failed?)

Peter Walsh

Chief officer

Croydon community health council

The Viagra saga is raising important issues for health policy- makers. On one hand the NHS, via the secretary of state, is restricting its availability through public funds, and on the other there is the fact that many people are willing and probably able, to pay for the treatment - and therefore take greater personal responsibility for their own health.

This issue may sew the seeds of a policy debate about the proper place of individual co-funding of care; Viagra is, after all, not the first treatment of its type (hormone replacement therapy is another), and certainly will not be the last.

I doubt whether the cost of Viagra will take money away from other areas of NHS priority; this is just a silly way to argue about health priorities in public. Perhaps men who take the drug may be happier, drink and smoke less, spend more time with their families, experience less stress, have fewer heart attacks and generally live healthier and better adjusted lives. So much could be gained, all for a 5 pill.

We certainly cannot continue with the present approach to health priorities without engaging the public, who have their own ideas about what they would like. It is worth remembering that the secretary of state has a wider responsibility for public health than just the NHS alone.

The difficulty this drug presents for policy-makers suggests that discussion on a third way in health is now overdue. It's a shame the government rushed the white paper.

Michael Tremblay

Amersham

Bucks

David Hunter ('Live from Leeds', 3 September) is absolutely right to highlight the almost total failure so far to pay proper attention to the impending genetic revolution in healthcare.

In 1995, we brought together 20 leading clinicians, researchers and managers to identify the key challenges which the new genetics would pose the NHS. Only recently have managers and professionals begun to grasp that genetics should be on their agendas now.

Adding to Hunter's excellent overview, perhaps we could highlight two immediate challenges revealed by our work since 1995. First, the pre-registration education of all professional groups gives inadequate attention to genetics. Nurses, for example, typically receive less than 10 hours' training in this field, usually from a non-specialist, and yet genetics will have a fundamental influence on both the physiological and psychological needs of their clients.

Second, the general public has a profoundly ambivalent - and volatile - attitude to the impact of genetics on their NHS. Our research reveals great popular excitement at the prospects for health gain, which could easily be overwhelmed by fear generated by the unregulated introduction of unfocused genetics testing and manipulation.

These issues - and others - need a detailed airing among managers and clinicians, followed probably by a series of policy shifts relating to service reconfiguration, capital development (including all new private finance initiative bids), professional education, and public engagement. We will be hosting the first major conference in this area next June, and copies of our research and other publications are available on request.

In the meantime, the NHS needs to raises its eyes just a little from waiting lists and immediate financial pressures to see the tidal wave heading its way.

Marcus Longley

Associate director;

Maggie Kirk

Rachel Iredale

Tony Beddow

Senior fellows

Genomics Policy Unit

Welsh Institute for Health and Social Care

University of Glamorgan

Your news story on NHS equality practice (page 2, 10 September) rightly pointed out that the December 1997 survey of trusts, whole showing massive compliance with the need to have in place equal opportunities policies, demonstrated that many trusts were not evaluating the results of this work or turning policy into action.

But this does not tell the full story. Throughout the summer, the NHS Executive's equal opportunities unit and the NHS Confederation held seminars throughout the country involving over 300 trusts. Trust chairs, chief executives and human resource directors discussed with trade union representatives and the equal opportunities unit how best to move monitoring into action. Examples of the 25 good practice case studies circulated with the survey results last week by the NHS Executive - but not mentioned in your story - were used to help participants see the way forward.

Each seminar produced a charter of commitment to mainstream and evaluate equal opportunities work. The seminar results have now been circulated to all boards of health authorities and trusts.

We are now working in the same way with health authorities and regional offices to ensure the message from the survey and the seminars make its way throughout the service and that everyone is aware of their responsibilities regarding equal opportunities. As Elisabeth Al-Khalifa, head of the equal opportunities unit, has said at each seminar, equal opportunities in employment are a crucial element in delivering the government's wider agenda of tackling health inequalities and social exclusion. We think it would be good to recognise the new energy emerging now in trusts and HAs to make that vital link.

Linda Smith

Chair

Lambeth, Southwark and Lewisham HA;

Jean Trainor

Director

Health Links

Former deputy chief executive, NHS Confederation

I worry about the complacency of Matt Tee's approach to the Institute of Health Services Management (Letters, 10 September).

The IHSM and NHS Confederation are very different types of organisation. The institute is a body representing individual, qualified member of a healthcare profession working in the NHS and beyond. The NHS Confederation represents employing organisations. If one takes the membership to be the boards of NHS bodies, one should not forget, therefore, that half the membership is there by political appointment. Membership of the confederation is by virtue of the fact that an employer pays for corporate membership. Matt Tee neglects the distinction that one represents individuals and the other organisations.

He appears also to confuse the roles of professional institutes and trade unions. While I share his concern about the potential of any current trade union to represent some of my interests, one does not belong to a professional institute for the sake of one's pay and conditions. The IHSM is not a trade union. But it does play an important role in defining standards in healthcare management, promoting professional development among healthcare managers and influencing and commenting on important policy matters on behalf of its membership and the profession.

Jill Turner

IHSM executive committee and chair - South & West region

I was interested to read John Henderson's letter (13 August) on a means of waiting list management in child and adolescent mental health services.

My own profession of clinical psychology has, over the past 10 years, researched a number of different approaches to waiting list management in mental health services. This research has all been published in our professional journal - Clinical Psychology Forum - published by the British Psychological Society. The approaches to waiting lists have included the management of referral input, the care process, throughput and discharge thresholds. Examples include opt-in systems, splitting assessment from treatment, brief therapy, improving patient compliance, and exploring different care options.

Managers and professional colleagues facing waiting list problems may wish to approach their local clinical psychology service to obtain copies of this research. Alternatively, readers can contact me to obtain a copy of the waiting list management reference list that I have produced.

WM Jellema

Clinical psychology manger (mental health)

Durham County Priority Services trust

Maiden Law Hospital

Lanchester

Co Durham

DH7 0QN

Tel: 01207-214795

I read with interest the In Brief item on collaboration between Ashworth and Sheffield Hallam University to offer a degree in forensic care (page 4, 27 August).

This qualification will not be the only of its kind. Kneesworth House Hospital (a medium-secure facility which is part of Partnerships in Care) has joined forces with Anglia Polytechnic University to offer a degree in forensic care studies, a modular programme leading to a BSc Hons, starting in September 1998.

Kneesworth House Hospital has a history of offering degrees to its staff, and recently had six nursing staff graduate with a BSC in professional nursing practice. A further three staff members are due to complete a negotiated forensic award with APU at the end of this academic year.

Colin C Campbell

Training and professional development manager

Associate tutor - APU

Kneesworth House Hospital

Royston

Herts

After reading your In Brief item on needlestick injuries (page 4, 20 August), I thought I would write to let you know what was happening at King's Healthcare trust on the same issue.

Last summer we set up a working party of senior clinicians - medics, nursing, occupational health, infection control, health and safety - to look at the issues of safer sharps-disposal and handling in the workplace, conducting in-depth interviews to collate opinion on best surgical practice and reviewing needlestick injuries reported to the occupational health department.

We found that needlestick injuries are common, with 2 per cent of staff reporting one each year, but it was felt that the majority are not reported. With some evidence suggesting many needlestick injuries are preventable, reducing these injuries could therefore not only minimise the medical risks to staff (of HIV and other infections such as hepatitis C), but reduce the costs associated with their treatment and follow-up.

We also found the chance of being exposed to infected body fluids can be increased in certain situations:

engaging in high-risk behaviour, such as re-sheathing needles and using fingers while suturing

during lengthy surgical procedures

staff are inexperienced

during emergencies

when dealing with unco-operative patients

when visibility is impaired

when re-sheathing of needles still occurs during intra-venous administration and during venepuncture

when risk assessment is poor, with inappropriate assumptions being made about patients and injuries.

Healthcare workers should be aware of the risks of transmission of blood- borne viruses and how to reduce them. It is equally important they know the procedure to follow should a 'sharps' injury occur, and of the existence of post-exposure prophylaxis against HIV. The Department of Health now advises three drugs, namely zidovudine, lamivudine, and indinavir, to be started as soon as possible after exposure to infected body fluids and continued for one month. This is not only costly, but side-effects are common leading to time taken off work.

We are now looking at providing an education/training pack on these issues, ensuring the training has a multi-disciplinary focus; at setting-up a 'hotline' to report incidences and seek support; reviewing occupational health and A&E services, and triage of staff who attend with needlestick injuries; and reviewing equipment usage when dealing with sharp objects.

Brendan Docherty

Practice development nurse

Directorate of nursing

King's Healthcare trust

Heretic