20 June 2016
Chair, Association of Clinical EmbryologistsAppeared in BioNews 856
Since its launch in 1948, the NHS has become the world's largest publicly funded health service and a beacon of what is possible to the rest of the world. Unless, it seems, you are finding it hard to conceive.
The NHS was born out of a long-held ideal that good quality healthcare should be a universal right, regardless of wealth. The first two articles of the NHS Constitution state this explicitly: '(1) The NHS provides a comprehensive service, available to all' and '(2) Access to NHS services is based on clinical need, not an individual's ability to pay'.
In Scotland they are getting this absolutely right (see BioNews 855). The National Institute for Health and Care Excellence (NICE) recommend three cycles of IVF and that's exactly what is provided via a national commissioning policy. In England, however, we are getting this catastrophically wrong because there is no consistent approach to commissioning. Most Clinical Commissioning Groups (CCGs) ignore the NICE recommendations, and some do not provide any IVF funding at all.
By way of example, consider my region, the East of England. For so many years it was the region that championed our cause and delivered exactly what NICE had recommended in their Fertility Guidelines published in 2004 – three full cycles of IVF or ICSI treatment.
Following the guideline review in 2013, the CCG consortium for the region decided to reduce IVF allocation from three funded cycles of treatment to two. From that point onwards we have seen a further rapid decline. In the last 12 months, two of the CCGs – South Norfolk and Mid Essex – have withdrawn their funding for IVF completely and a third, Bedfordshire, is consulting on removing provision.
Earlier this month a fourth East of England CCG, Cambridgeshire and Peterborough, informed secondary care providers that they were reducing their NHS provision from two cycles to one, with immediate effect and with no notification or consultation period.
The CCG said that this decision had been made due to cost pressures and that a consultation on the future funding of IVF activity would take place later in 2016. I fear that this means they will be proposing to withdraw funding in its entirety. While I have genuine sympathy for the plight of the CCG and realise they would not have taken this decision lightly, I do feel that it seems the infertile are always among the first to suffer when cutbacks must be made.
Some people ask why funding for infertility treatment is important when nobody dies from infertility. Let me take a step back and offer an alternative view. We must remember that infertility is a disease just like any other and is categorised as such by the World Health Organisation. We must remember that the vast majority of patients struggling to conceive find themselves in this situation through no fault of their own; infertility is rarely 'self-inflicted'.
We must consider the effects that lifelong infertility and childlessness can have on an individual or couple; depression, anxiety and social isolation, all of which can put a greater cost pressure on the NHS than taking the proactive view and commissioning appropriate fertility treatment. And then we must consider if it is fair and equitable that one person might receive no NHS-funded cycles and another up to three, with that decision based solely on where they happen to live.
In England only 17 percent of CCGs commission the NICE-recommended three cycles of treatment. What's stopping the other 83 percent?
Such inequality isn't what the NHS is about. We've created a scenario where access to treatment is based on a person's ability to pay, contrary to the NHS Constitution.
Yet it's possible to get it right, as the Scottish example shows. Meanwhile, in England we're making fair provision less possible. By allowing local CCGs to control budgeting for IVF treatment we have created an environment where they are forced to look at extreme options to balance the books.
Such a situation isn't in the best interests of the public or the NHS. We should look at the Scottish model as an example of how to provide fertility treatment equitably, and follow that lead.