22 April 2013
ByAppeared in BioNews 701
It is widely argued that there exists a 'postcode lottery' in the provision of IVF on the NHS and the evidence shows (see BioNews 611) that not all PCTs funded the maximum number of cycles recommended by the National Institute for Health and Care Excellence (NICE). What may not be so well known, however, is the cost effectiveness analyses and political culture in which decisions regarding the state provision of fertility treatment are reached.
The Progress Educational Trust's debate, 'NICE Try...But is anyone listening?', sponsored by the British Fertility Society and held at the Royal College of Obstetricians and Gynaecologists on Tuesday 16 April, looked at the updated NICE guideline on fertility and the provision of IVF on the NHS. It went beyond the axiomatic argument for effective and equal treatment of fertility patients on the NHS and considered the impact of the radical structural changes to the NHS on the state provision of IVF through the replacement of PCTs with Clinical Commissioning Groups.
At least two central critical themes emerged from the debate, which followed short presentations by some of those who took part in the update process: a critique of method and a critique of measure.
First, was the approach adopted by NICE in its determination of its new recommendations on fertility flawed? In its review of the guideline, NICE was applauded by Dr Yacoub Khalaf, director of Guy's and St Thomas' NHS Foundation Trust's Assisted Conception Unit, for its transparency and opening up its deliberations to scrutiny. However, responding to a question from an audience member on how the cost effective analysis in the age recommendations were reached (NICE recommends that the upper age limit women be increased from 39 to 42-years-old), Dr Khalaf explained that, in his view, the methods of cost-analysis calculation employed by NICE were untested and not widely accredited.
The new guideline had much to be commended for, Dr Khalaf outlined in his presentation, including its recommendation on unexplained fertility, and extending funding for older ages, but its process of decision-making might have been improved by taking sufficient account of the psychological factors associated with infertility (see BioNews 684).
Others said that NICE was necessarily or unavoidably constrained by its remit and available evidence. Peter Taylor, a member of the Guideline Development Group for the update, said NICE can only achieve what it can within the parameters of the Government's commission.
Another accusation against its methodology was about the weight given to evidence. An audience member asked why its recommendation on intrauterine insemination (IUI) was based on a small number of clinics showing poor success rates that did not reflect the true figure. Dr Khalaf broadly agreed, responding that some decisions were based on weak evidence. In support of IUI, he said fertility patients should be allowed the choice.
Dr Allan Pacey, chair of the British Fertility Society and chairing the evening debate, admitted the IUI decision was controversial but that it was made on the best available evidence at the time. Discussion that followed pointed to the onus being on clinics to produce more evidence to support decision making.
A second theme that emerged was on how value in the determination of resource allocation operates in the fertility context. Audience members pointed out that fertility care is not just about efficiency and value calculations. Precisely how is value measured in fertility? Dr James Kingsland, president of the National Association of Primary Care, conceded that fertility does raise sensitive issues and that value is emotive, but that the bottom line is that there is an absolute cash limit in the NHS and there is a resource issue with every decision made.
In his presentation, Dr Kingsland emphasised that the culture of accountability the new commissioning process will bring may promote more decisions sensitive to patient needs. He said that if NHS commissioners pay little attention to the NICE guideline then they must justify their decision by reference to their role in providing clinical care. He emphasised that patient care, and not rationing, will be central to the new commissioning process and that costs alone will no longer be accepted as a sole justification for denying the services that patients want.
Taylor hoped that the new local commissioning structure will better allocate resources to allow savings made to increase funding elsewhere. In his presentation, Taylor said the 2004 guideline adopted a one-size-fits-all approach that was not suitable to local needs, leading to considerable variation as to how it was applied.
Value and quality were to be promoted, noted Taylor, but it was still unclear after the debate what NICE thought of as 'value' in fertility treatment. Surely it is the birth of a healthy single baby, one audience member suggested. Dr Khalaf argued that a clearer determination of efficiency could be achieved through linking funding to single embryo transfer, as has been done in Belgium and the state of British Columbia in Canada, where significant savings have been made.
What we learned from the evening was that notwithstanding the positive steps forward taken by NICE in its update of the fertility guideline, there remains a tension between the emotions attached to infertility (and the feelings that it is not given due recognition compared with other diseases) and the methods of calculation employed by health economists in their cost analyses. It remains to be seen what impact the new commissioning structure will have on the provision of NHS services and fertility treatment, however.