Changing perceptions, changing lives: commissioning fertility services in the age of austerity

Last week BioNews reported the results of a national survey undertaken by the National Infertility Awareness Campaign (NIAC). The survey of England's 211 Clinical Commissioning Groups (CCGs) sought to determine how closely CCGs were following the National Institute for Health and Care Excellence (NICE) guideline recommendations.

In 2011, the All Party Parliamentary Group on Infertility published a similar report detailing levels of IVF provision throughout the country. It found that over 70 percent of NHS Primary Care Trusts (PCTs) were not providing the recommended three full cycles of IVF to eligible couples.

Now, three years later, NIAC's data shows that there has been a very real and very disappointing lack of progress.

Over 70 percent of CCGs were still offering less than three full cycles as of Summer 2013. Admittedly, many of these CCGs were, and still are, reviewing their assisted conception policies. However, a great number have chosen to continue with the policies of their respective PCTs for the foreseeable future.

It is of fundamental importance that commissioners understand the reasoning behind NICE's three-cycle recommendation. Some couples produce more viable embryos than others, so those that produce a small number are immediately placed at a disadvantage if they are not allowed to have more than one cycle of IVF treatment. Not all patients will require three cycles, but it is essential that the option is made available to them in the event that further treatment is needed.

The cumulative effect of such a policy would be (and this has been shown to be true) to greatly increase the chance of a successful outcome — and by 'outcome' we of course mean a healthy newborn baby. The fertility clinic Bourn Hall in Cambridgeshire recently announced success rates of over 40 percent for NHS-funded patients on their first IVF cycle. Seventy-eight percent of these patients could expect to achieve a pregnancy within three cycles.

Yet only a few weeks ago, NIAC received confirmation that the 19 CCGs within the East of England - Bourn Hall's own patch - were considering a wholesale reduction in the number of cycles funded from the recommended three to two for couples where the woman is under 40. Indeed, some have already made the move.

The rationale behind this policy position appears to have been based on a regional level review of the academic evidence on IVF success rates. In other words, representatives from the region undertook a task that NICE itself did throughout the whole of 2012 and early part of 2013, only this time on a much smaller scale and incorporating only a fraction of the studies NICE reviewed in its 2013 guideline.

It is against the spirit, if not the word, of the NHS Constitution to replicate the processes NICE uses to produce its guidelines, as stated in the latest Pharmaceutical Price Regulation Scheme report (page 20).  The emphasis on academic studies and live birth rates reflects a clear disregard for the work NICE already carries out and yet omits NICE's analysis on treatment cost effectiveness.

Even more surprising, some might say bizarre, is the fact that the lead procurer for the region, East and North Herts CCG, have decided to stick with three cycles (following subsequent evidence presented by their public health team) while the rest of the region are continuing to consider a move down to two cycles.

Several CCGs, including those within the East of England, have changed their policies, or are looking to change them, to incorporate NICE's recommendation that a select group of women aged 40 to 42 be offered one cycle of IVF. However as NIAC feared, this extension of the criteria (which effects only a small number of patients) is being used to justify a much larger reduction in the service offered to those aged under 40. Indeed, some even claim that these changes will result in more women being eligible for treatment.

Horse-trading of criteria to give the appearance of adherence whilst seeking to maintain or cut funding cannot be allowed to continue if we are to truly improve NHS fertility treatment, a service that is still to this day struggling to get off the ground, despite having been launched over a decade ago.

A study published in 2012 ranked the UK third from bottom in a list of 23 European countries when it came to reimbursement of IVF services - only Russia and Ireland fared worse.

The problem is deep-rooted and is fuelled in some areas by outdated perceptions of fertility treatment and those in need of it. While not all commissioners lack sympathy and understanding, the service will remain in some people's eyes as simply 'not a priority' - end of story.

A large number of health professionals are already actively trying to change attitudes and are working wonders to try and increase awareness of the importance of fertility treatment.

NIAC's report offers us another snapshot of provision across the country and should help change perceptions, but what is crystal clear is that without national intervention we are running the risk of another three years of complacency and sub-standard fertility services.