As a consultant clinician working in one of the four NHS tertiary fertility units in Scotland, a member of the Scottish Fertility Group and the British Fertility Society, I was somewhat surprised to read the objection from The Association of Clinical Embryologists (ACE) in BioNews 776 about proposed plans to devolve legislative powers for fertility treatment to the Scottish Government. Somewhat surprised because this has not been discussed with clinical providers in the Scottish NHS to date, nor something that would appeal – even, I would suggest, to those who voted 'yes' to independence of our nation.
Apparently this has been proposed by the Scottish Council on Human Bioethics, an 'independent, non-partisan, non-religious Scottish charity composed of doctors, lawyers, psychologists, ethicists and other professionals from disciplines associated with medical ethics'.
Objections from ACE include the concern that devolved fertility legislative powers could lead to increased fertility tourism and a perceived or realised double standard in the care available to patients within the UK. Sadly this concern is already a reality. Firstly, all self-funded patients have the potential to be fertility tourists. Secondly, Mr Harbottle references Clinical Commissioning Groups (CCGs) and the fact that NHS-funded fertility treatment is available at differing levels across the UK, leading to a 'postcode lottery' for patients where some may receive up to three full cycles of IVF funded by the NHS, while others receive nothing at all. However, it is worth noting that CCGs are organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England. In contrast, funding streams are healthboard-based in Scotland.
Moreover, since July 2013 the Scottish Government has established nationwide eligibility criteria for IVF/ICSI treatment, applied to all. In Scotland there is no postcode lottery, and a vision, now reality, that all NHS patients (with very few exceptions) undertake tertiary fertility treatment within 12 months of referral. This policy was delivered in response to a report published in 2000 by the Expert Advisory Group on Infertility Services in Scotland (EAGISS), established in 1998 to advise the then Scottish Office on the provision of effective services across Scotland. In addition, enhanced financial commitment of the Scottish Government to fertility services has resulted in recent funding of state-of-the art equipment for all Scottish NHS tertiary units.
Mr Harbottle's statement also includes reference to the National Institute for Health and Care Excellence (NICE) national Fertility Guideline (published in 2004 and revised in 2013), which presents systematically developed recommendations, based on best available evidence. However, it is worth noting that NICE guidance is not mandatory. Indeed, the way NICE was established in legislation means that their guidance is officially 'England-only'. Decisions on how NICE guidance applies in Wales, Scotland and Northern Ireland are already made by the devolved administrations, albeit that they are likely to be involved and consulted with in the development of the aforementioned.
The Scottish Intercollegiate Guidelines Network (SIGN) develops evidence-based clinical practice guidelines for the NHS in Scotland. SIGN guidelines are similarly derived from a systematic review of the scientific literature and are designed as a vehicle for accelerating the translation of new knowledge into action to meet our aim of reducing variations in practice, and improving patient-important outcomes. To date, there is no equivalent SIGN publication concerning fertility guidelines, perhaps to avoid 'reinventing the wheel' and/or respect for a consistent approach and standardised UK practice?
Mr Harbottle states 'it is highly evident that within the UK, at both a governmental and professional level, patient safety and achieving and maintaining best practice standards in the provision of fertility treatment are taken very seriously'. His concerns of devolved fertility legislation include loss of clinical consistency, problems with service delivery, difficulties accessing local treatment, as well as difficulties with gamete/embryo transportation between UK clinics, all of which are unfounded.
NHS Scotland is clearly committed to provision of the best health care possible. Health Improvement Scotland is the national healthcare improvement organisation for Scotland and incorporates the Healthcare Environment Inspectorate (reducing the risk of healthcare associated infection), Scottish Health Council (supporting NHS boards to involve staff, patients, carers and communities in the development of health services), Scottish Health Technologies Group (providing advice on the clinical and cost effectiveness of healthcare technologies that are likely to have significant implications for patient care in Scotland), Scottish Medicines Consortium (accepting use of newly licensed medicines that clearly represent good value for money to NHS Scotland) as well as SIGN. Furthermore, recent major strategic investments in clinical research infrastructure, NHS Scotland and the University medical schools in Scotland are committed to positioning Scotland at the forefront of medical research.
I concur with Mr Harbottle that a single legislative framework, in which clinics are licensed and regulated by the Human Fertilisation and Embryology Authority (HFEA), represents national (and internationally respected) standards that should be defended and maintained. Furthermore, I personally reject the notion that Scotland is looking to devolve from this framework, and am relieved to read that ACE does not infer that the Scottish Parliament is incapable of acting safely and responsibly when considering provision for practices pertaining to human embryology, genetics or abortion.
However, it is thanks to Holyrood that NHS Scotland has (so far) been protected from Westminster reforms which have seen private competition playing significant roles in other parts of the UK NHS. I would gently counter that Scottish administration of NHS fertility treatment is already successfully devolved, and perhaps NHS England should look north to see how NHS Scotland has achieved fair and just access to IVF/ICSI, astute and evidence based clinical care, and equality on a national basis.