In 1948, UK health secretary Aneurin Bevan spearheaded the creation of the National Health Service (NHS) with the aim of providing healthcare access to all, irrespective of a patient's financial situation. The objective of the new service was described as providing:
'…all medical, dental, and nursing care. Everyone-rich or poor, woman or child can use it or any part of it.'
The NHS has since become the world's largest publicly funded health service and can boast of being one of the most efficient, most egalitarian and most comprehensive health systems in the world. Clinical decision-making is guided by best evidence-based guidelines usually produced by NICE (National Institute for Health and Care Excellence).
But variation in clinical service provision means that NICE recommendations on fertility treatment are not adhered to and the NHS's core principle of 'equity of access' is undermined – and this situation is being made worse by recent cost-cutting exercises across the England.
The NICE guideline states that up to three cycles of IVF or ICSI (intracytoplasmic sperm injection) should be available to: women aged 23 – 39; those who have an identifiable cause of infertility such as blocked fallopian tubes; and those who have had more than two years of fertility problems. Women aged 40-42 who have not conceived after two years of regular, unprotected sex, should be offered once cycle of treatment.
As things stand, only Scotland complies with the guideline offering three cycles of treatment, Wales currently offers only two cycles and Northern Ireland until recently has offered only one cycle. But now even this is in jeopardy in Northern Ireland.
The Health and Social Care Board, responsible for commissioning of health services in Northern Ireland has announced £70 million cost-cutting proposals to meet budget targets by March 2018. Belfast Health Trust, the biggest of all Northern Ireland's health trusts has been tasked with making savings of £23.6 million.
The proposals in this Trust include five months deferral of fertility treatments at the Regional Fertility Centre at Royal Victoria hospital, Belfast, which will save £0.75m. This will affect 320 people and increase waiting times from nine months to at least 14 months.
Other suggested savings include: staff cuts of agency nurses and locum doctors amounting to a saving of £1.75m; cuts to elective surgery cases saving £2.95m with a resultant delay to 2150 surgical day cases; domicilary care cuts saving £0.75m and resulting in a five-month increase in waiting times; £2.3m saving by cutting nursing home and residential home placements resulting in further 'bed-blocking'; and the deferral of high cost drug treatments for approximately six months, saving £4.5m and affecting 200 people.
These cuts are occurring against a political backdrop of a collapsed devolved government since January 2017 and health service investment that has not kept up with inflationary pressures. The Stormont impasse means that a previously planned healthcare reform agenda has not progressed. In the interim, Northern Ireland Department of Health civil servants must work within the budget available. In terms of socioeconomics, Northern Ireland has higher levels of poverty and lower wages than most of the UK and a high proportion of the workforce are public servants.
Further uncertainty will arise for healthcare in Northern Ireland if cross-border healthcare schemes are affected by a hard Brexit. This issue was raised by Ireland's Minister for Health Simon Harris, last week. Shared tertiary care arrangements with Dublin in areas, for example, including paediatric craniofacial, cardiothoracic surgery and oncology will be made more difficult post-Brexit. This will put further strain on health care budgets in Northern Ireland and increase the likelihood that services such as fertility treatments are not reinstated.
The long-held ideal of universal good quality healthcare, regardless of wealth is evidenced by the first two articles of the NHS Constitution which state as follows:
(1) The NHS provides a comprehensive service, available to all
(2) Access to NHS services is based on clinical need, not an individual's ability to pay.
It is clear that there is significant financial burden on the NHS and that cut-backs in fertility services are not taken lightly. However, infertility is a recognised disease by the World Health Organisation and the significant psychosocial effects of infertility on individuals and couples can put a greater and longer term cost pressure on the NHS.
Possible solutions to address this inequity of access across the UK include looking at the Scottish model as an example of how fertility treatment could be offered equitably and stopping the variability of funding offered by different CCGs (see BioNews 894). The potential procurement ability of several CCGs working together may lead to cost savings and subsequent reduction in the variation of IVF costs nationally.
A standard cost for IVF for NHS procurement could be set across the UK. And CCGs could work together collaboratively to increase shared knowledge and to improve decision-making especially where individual funding requests occur.
The current variation in IVF funding across the UK is contrary to the ideals of Aneurin Bevan back in 1948. This was recently echoed by Dr Simon Fishel, a leading IVF practitioner in the UK, when speaking to the Guardian newspaper in August,
'You have to treat citizens equally and this is a deliberate inequality and obfuscation...'
'If the country decides it will not fund IVF then fine, that is a decision that affects everyone...'
In terms of equity of access to reproductive care, the European Society of Human Reproduction and Embryology recommends that infertility treatment should be included within the basic health care allocation in relatively affluent societies. It is clear that Northern Ireland currently has difficult socioeconomic and political challenges, however it is still considered an affluent country and therefore its citizens should have access to infertility treatment, ideally as per recommendations by NICE.