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NHS funded IVF: is it really so NICE out there?

14 February 2005
By Professor Brian Lieberman
Director of Reproductive Medicine, St Mary's Hospital Manchester and Manchester Fertility Service.
Appeared in BioNews 295
The failure of the UK government to provide, or to identify additional funds for NHS funded IVF treatment is of increasing concern to many thousands of infertile couples, led to believe that they would receive such treatment following the report by the National Institute of Clinical Excellence (NICE) in February 2004. Speaking immediately after publication of the guidance, the Health Secretary, Dr John Reid, indicated that 'as a first step...by April next year (April 2005) I want all PCTs, including those who at present provide no IVF treatment, to offer at least one full cycle of treatment to all those eligible. In the longer term I would expect the NHS to make progress towards full implementation of the NICE guidance'. Dr Reid stopped short of setting a timetable for the full implementation of the NICE recommendations of three cycles per couple but also said, 'Our immediate priority must be to ensure a national level of provision of IVF is available wherever people live'.

The significance of Dr Reid's announcement should not be underestimated. This was the first time that a UK government had accepted that infertile couples requiring IVF should be treated on the NHS - if only to put the UK on a level playing field with other European countries. But have his fine words been translated into actual treatment for patients? The Independent on Sunday reported on 29 January this year that many cash-strapped PCTs had failed to meet these targets. This may well be the case, as the government has failed to provide additional funding for IVF. The Minister was aware that the additional cost would be in the realms of £85 million per year. It is unacceptable to simply pass this responsibility to PCTs, who have quite properly used any new monies to meet their existing priorities. Additional funding should have been identified for this new service.

The infertile do not ask to be treated any differently from the many others who have legitimate expectations of treatment within the NHS, they simply wish to be treated similarly. It is a little-known fact that IVF waiting lists are excluded from official waiting list statistics. Surely, as IVF requires an operation, these should now enter the official waiting list targets and the infertile should not be required to wait any longer than others? The government has established strict time guidelines for the first GP hospital referral (outpatient consultation). Thus, those who require IVF should now be seen within 13 weeks. The time from listing a patient to first definitive treatment is then 13 weeks. The total waiting time for IVF should now not exceed 26 weeks if the infertile are to be treated as others are within the NHS.

By 2008, Trusts will be required to ensure that the total 'patient journey' (a lovely cosy term) should not exceed 18 weeks. The government has also indicated that 'patient choice' will become an option for all in 2006. Might we assume that the infertile requiring IVF be given the same rights as others to exercise this choice?  

However, paying for IVF is not the only problem with NHS funding, as the costs of caring for IVF twins within the NHS are considerable. It would not be unreasonable for the NHS to impose regulations to reduce the number of embryos transferred to one, in women at high risk of multiple births, as ultimately the NHS will be expected to pick up the tab for the 20-30 per cent twin live birth rate after IVF treatment. This has already been achieved in Scandinavia.

It is no longer acceptable for IVF in the NHS to be determined by the place of residence or the location of the patient's GP. The so-called 'postcode lottery' for IVF treatment remains, even in Manchester where NHS IVF has been offered since 1982. Nevertheless, the majority (62 per cent) of PCTs are NICE compliant in purchasing three cycles, 31 per cent a single cycle - meeting the minimum required by the Health Secretary - and 7 per cent offer two cycles. It is not unrealistic to hope that the latter two groups will heed John Reid's words, with respect to moving to full implementation of the NICE guidance. None of the PCTs have indicated that they will be reducing the number of cycles and they all have waiting lists in excess of two years.

The first regionally-funded NHS IVF unit was established at St Mary's Hospital in Manchester in 1982. At the outset, guidelines were formulated to establish priority for treatment to the most needy and those most likely to be successful. These have withstood the test of time. We usually offer treatment only to couples comprised of childless infertile people who have been cohabiting for at least three years. Childless is defined as having no children (persons aged under 16) resident with them by the current or previous relationships, or by adoption. The female patient must be aged under 40 and the male under 55. Since 1991 we have in addition followed the Code of Practice of the Human Fertilisation and Embryology Authority (HFEA).

The HFEA has a statutory duty to regulate treatment by IVF and donor insemination and is quite properly separated from the funding of such services. The licence fees charged by the HFEA are in the final analysis imposed by the Treasury and have precious little to do with the funding of NHS IVF treatment. As the majority of IVF is provided within the fee-paying sector, it could be argued that a significant proportion of the cost of regulation is being borne by the private sector, hence saving cost to the government and to the NHS.

The UK leads the world with the regulation of IVF treatment and embryo research. Although the 1990 Human Fertilisation and Embryology Act is imperfect, it is not fundamentally flawed. All are agreed that the Act is in need of revision, but regulation has been an unqualified success and any future Act should build on the strengths of the original. The next few months will see politicians at their very best. In Labour's first term they agreed to place infertility within the NHS. This was duly accomplished in their second term, via NICE. Might the wishes of the childless and infertile be granted in a third term, by full funding? After all, I am only asking, on behalf of all the thousands, for a mere £85 million out of an NHS budget exceeding £87.2 billion in 2005-2006.

SOURCES & REFERENCES
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