I welcome the letter from Alan Doran, Interim Chief Executive of the Human Fertilisation and Embryology Authority (HFEA) to all Directors of Public Health in England on the subject of multiple births and commissioning IVF services. Why? Let's be honest! In England, even before the move to single embryo transfer (SET), we've had a crazy, and totally unfair, situation in relation to NHS funding for fertility treatment, in particular for IVF/ICSI. Therefore, we've always needed all the help we could get, by way of pressure, to make PCTs fully implement the NICE (National Institute for Clinical Excellence) Fertility Guideline of three full cycles. By the way, please don't think I am ignoring the rest of the UK because I am not - I'll come back to that a little later.
The move towards SET, started with a HFEA decision announced at the British Fertility Society Winter College 2007. The HFEA said it had agreed a policy based on outcome and designed to maximise clinical discretion would be the best approach with the aim being to reduce the IVF multiple birth rate from the current 24 per cent to 10 per cent over a three-year period, requiring the team in each centre to develop a multiple birth protocol to be in place by January 2009.
But everyone, and I mean everyone, has said that those patients to whom SET might be recommended are more likely to accept it is if they are assured equitable treatment in line with the NICE guideline. And that is why the Alan Doran's letter is a welcomed piece of pressure by those of us who have been campaigning for over 16 years across the UK to increase the level of NHS funding for fertility treatment.
In his letter, Alan outlined and justified the key elements of the policy: 'The rationale behind requiring clinics to develop their own SET criteria (rather than imposing any such criteria) is because different factors might be relevant at different clinics.' He gave the example that some centres may offer blastocyst transfer, and others may specialise in treating older patients and that these differences may materially influence appropriate SET criteria in that particular centre's strategy and the HFEA believed that it is vital for this policy to be sensitive to such variables. In other words, it was for the clinic to decide who gets SET and who doesn't.
So why do we find ourselves with the additional fight now to convince PCTs that SET is NOT for every patient and should NOT form part of their commissioning policy? Because we know that East Midlands Specialised Commissioning Group is insisting that, in order to have NHS funding, all patients must have SET. That is completely irrespective of age, quality of embryo or any other factor! East Midlands SCG covers a huge part of England and covers 9 PCTs (1). Alan Doran's letter made it clear that '...it would ... be inappropriate, for example, to specify that all patients should receive single embryo transfer (irrespective of their age or prognosis) or to fail to distinguish between blastocyst and cleavage-stage embryo transfer. There is no 'one size fits all' policy that is evidence based'. As I said last week (2), this is not what's being recommended, is not clinically appropriate for some patients and is therefore not a cost-effective use of the PCTs resources. Nor is it what experts working in clinics and the HFEA are saying. So they must review their funding decisions urgently!
Infertility Network UK (I N UK) have been working on a project, funded by the Department of Health (DH), to identify good practice in the provision of infertility service in PCTs in England. Our work to date has identified that one of the barriers is that commissioners need a clear understanding and knowledge of treatments and commissioning options. This was acknowledged in the Interim Report of the Expert Group on Commissioning NHS Infertility Provision, published last summer. I believe this is a reason for decisions being made such as that of East Midlands SCG above.
Latest developments (and therefore more pressure on PCTs) are that the DH is once again doing a survey of PCTs in England to monitor their implementation of the NICE Guideline. The I N UK project will produce a document on access criteria aimed at helping PCTs standardise these criteria (which currently vary widely) and will look at things like considering the position of patients where one partner has a child from a previous relationship but the other partner has never had a child. It will also look at lifestyle issues such as smoking and BMI. What we don't want is patients not even being referred to an infertility specialist in order to access support they need to stop smoking, or to lose weight, etc. The final report of the Group plus recommendations based on the results of the I N UK project will be announced this summer.
As I indicated earlier, our work doesn't simply focus on England - but across the whole of the UK. There are problems everywhere. Scotland has waiting list problems but does fund three cycles in the main. Wales hasn't moved on from the announcement in 2005 of one fresh cycle for all although they are reviewing - but our latest feedback indicates no increase in the number of cycles and the possibility of going from central guidance to local decision making. Northern Ireland has reduced from two cycles to one - but do allow couples who already have a child to access fertility treatment.
Let's face it - it's a mess! We need everyone to get involved and help us to fight this great injustice of funding for infertility treatment - before it is too late for too many couples.
If you want to know how you can help, please contact me - anytime!
Sources and References
1) Derbyshire County, Derby City, Bassetlaw, Nottinghamshire County, Nottingham City, Lincolnshire Teaching, Leicestershire County and Rutland, Leicester City Teaching, and Northamptonshire Teaching.