Fertility services in the new NHS

The decision has been made. Fertility services will be commissioned at a local level from April 2013 onwards (1).

From next year, local GP-led Clinical Commissioning Groups (CCGs) will take on the commissioning responsibilities of Primary Care Trusts (PCTs), with the latter due to be abolished in April 2013. This now includes responsibility for commissioning fertility services such as IVF treatment.

The recent decision by Government ministers marks an end to months of uncertainty and speculation. Until last month, there was a possibility that fertility would fall under the remit of the new NHS Commissioning Board (NHSCB) - a national body which is due to become fully operational next year. The Board will commission services for a number of specialised conditions and oversee the activity of the CCGs.

The news has disappointed groups such as the National Infertility Awareness Campaign (NIAC), which would have preferred to have seen IVF commissioned on a national level. Their concern stems from the fact that devolved decision-making could potentially create an even more fragmented system than before. As of 2011, over 70 percent of PCTs were failing to provide the three full cycles of IVF to eligible couples as recommended by the National Institute for Health and Clinical Excellence (NICE).

Currently there are 151 PCTs in England and there will be 212 CCGs. The fear is that the greater number of CCGs will lead to an asymmetrical commissioning system in which conditions such as infertility are subject to an even wider postcode lottery.

That is the fear, but there is also cause for optimism.

In March, the National Quality Board at the Department of Health referred a number of new topics to NICE, including fertility. These topics will be processed into NICE quality standards by 2015. Quality standards set markers of best practice for health professionals and are expected to inform the content of the Commissioning Outcomes Framework (COF) - the mechanism by which the NHSCB will hold CCGs to account. The COF will in turn, inform payment mechanisms and incentive schemes like the Quality and Outcomes Framework for GPs.

So in theory, the measures that are being taken could be quite effective. At the recent 2012 NICE annual conference, Health Secretary Andrew Lansley said that 'quality standards should become the backbone of the commissioning system' (2). The incentives certainly look to be there, but what happens if CCGs just decide to do things their own way? Isn't local autonomy the whole idea behind local commissioning anyway?

Right now it is unclear what powers the NHSCB will have to intervene in instances where a CCG is not following NICE guidance. At the 2012 NICE annual conference Professor Malcolm Grant, chair of the NHSCB stressed the importance of ensuring that NICE's quality standards and advice do not go unheeded (3).

NIAC has learned that the Board will also be producing its own guidance for collaborative commissioning of infertility services, to sit alongside the NICE guideline and quality standards on fertility. One would expect this third piece of 'guidance' to differentiate itself from its NICE counterparts, but it is perhaps expecting too much to think it will include a punitive clause.

If you are a real optimist then you might argue that there is no need for a punitive system to be in place. NHS North Staffordshire's recent decision to fund IVF for the first time (4) was, after all, sanctioned by the new local shadow CCG. Indeed, GPs may well be more naturally inclined to commission such services for their local population.

The jury is out on that one.

One thing is certain. This latest decision by ministers marks a fork in the road and it will not be apparent for some time whether they have chosen the right path. What is clear however is the relatively short time available before CCGs take on their new commissioning responsibilities. The key challenge now for the Health Secretary is to ensure that fertility services do not suffer in the short term as a result of the transition to local commissioning.