CROYDON COMMENTARY: Three-quarters of those who responded to a recent consultation on local health services said that fertility treatment should be offered on the NHS. Then the NHS bean-counters, who had failed to review the service for eight years, announced they were going to cut it anyway. KIRSTIE SMITH on another example of health service policy which is forcing more people to go private

When a couple makes the decision to try for a baby, it’s an exciting time. When it is not possible for this to happen naturally, it is a devastating blow.

There can be all sorts of reasons why it’s not possible, but what’s important is not to look to apportion blame but to put all energies into “what next”.

Assisted conception – using In Vitro Fertilisation, or IVF – or intracytoplasmic sperm injection (ICSI) is a big decision and often a last resort. It has a huge impact on couples, not only physically but mentally and financially.

So when an area makes a decision to remove a couple’s chance on the NHS, that adds to the burden. Infertility affects 1 in 7 couples and is the second most common reason a woman visits her GP. It is recognised by the World Health Organisation as a condition for which medical treatment should be provided. But it won’t be provided in Croydon, if the cuts in services recommended by the local Clinical Commissioning Group are approved by the health minister, Jeremy Hunt.

In England and Wales, guidelines from NICE, the National Institute of Clinical Excellence, state that for the best chances of successful IVF treatment, three full cycles are recommended. For some time, the NHS in Croydon has provided only one.

Croydon is not the only CCG to offer only one, but still, it only offers one. Against the guidelines of three full cycles. This is for women under 39 years who have had unexplained infertility for at least three years. NICE guidelines are two years. After three years, Croydon couples are referred for tests. The first lot of tests have up to a 12-week waiting list.

After these tests, there are further investigations and when, finally, a couple is referred for IVF, in Croydon there can be up to a six-month waiting list. That is a long time to be trying, and failing, to have a baby.

After they decided that IVF fell into the services which offer “limited clinical effectiveness and/or poor value for money”, Croydon CCG consulted with the public. Over an eight-week period at the start of the year, the CCG engaged face-to-face with more than 330 Croydon residents, patients and professionals and received a total of 467 written responses through the online or paper survey.

The results of the consultation show that 77 per cent replied that Croydon CCG should opt to maintain one cycle of IVF for women 39 years old or younger. Just under a quarter of respondents, 23 per cent, thought the CCG should stop the routine provision of the IVF service.

Let’s just stop and consider that. More than three-quarters of the people the CCG consulted thought that one cycle of IVF should continue to be provided by our local NHS. Yet, the CCG felt, after receiving and reading the comments, they recommended decommissioning the service.

So what was the point of the consultation?

As I’ve said before, and as we all know, the NHS is having to save money. It’s going to be hard to decide where those savings can be made, but an average of 94 patients/couples received IVF/ICSI treatment each year for the past four years under the Croydon Health Services block contract. This equates to approximately 0.023 per cent of the CCG population. Sounds like easy pickings.

Government heath minister Nicola Blackwood: agreed that NICE guidelines on IVF were fair and robust

In addition, the block contract that the CCG has in place to provide this service has been in place since 2009 and has not been “significantly reviewed” during that time. It’s 2017. So that’s an eight year contract that has never been reviewed. How on earth is that good business sense?

I’ve changed my home services several times since then; is there no comparison site to compare IVF contracts? Someone get Martin Lewis on the blower!

The possible decommissioning of the provision for IVF was debated by Parliament’s Backbench Business Committee on January 19. The item was raised by Steve McCabe, the Labour MP for Birmingham Selly Oak and supported by Tom Brake and Ed Vaizey. It was responded to by Nicola Blackwood in her role as the government’s public health minister.

It was called a debate, but actually they all seemed to be agreeing. They agreed that there was urgent need for change. They agreed on the NICE guidelines but noted that they are not mandatory. They said the guidelines were robust and fit for purpose. They stated that four CCGs had already decommissioned IVF as a cost-saving measure and that 1 in 10 CCGs in England is consulting on it. They suggested that rather than a postcode lottery, areas under financial pressure need to become more efficient and look at how other areas are managing their funds to be able to provide IVF.

Fertility Fairness, a national umbrella group, undertook an audit of CCGs. They found that 16 per cent of CCGs offer the NICE-recommended three full cycles; 24 per cent did so in 2013. Today, 60 per cent of CCGs, like Croydon, offer one cycle. Only four out of 209 CCGs comply with NICE’s definition of a full cycle.

In reality, this policy of offering just one cycle of IVF treatment means that many parts of England are wasting resources, as incomplete cycles are rarely successful and effectiveness is compromised.

Some CCGs have introduced additional criteria by lowering the maximum age at which women may be referred for the treatment, non-eligibility if one of the couple already has a child from a previous relationship or if a couple has miscarried in the last three years, and prescribing that same-sex couples have to privately fund at least six cycles of treatment prior to accessing NHS resources.

Other figures suggest that the cost to the NHS of commissioning one cycle of IVF varies from £1,300 to £6,000 across the country with no explanation. Technologies in IVF are moving forward and prices are falling, but the NHS is not seeing the benefit of this as there is no national tariff and some are stuck in contracts that haven’t been reviewed.

In 2016-2017, it is projected that 108 completed cycles will take place at a cost to Croydon’s NHS of £845,240. That’s £7,826 per cycle. It seems Croydon’s CCG is paying well over the odds.

Research suggests that the high cost of IVF in the private sector is forcing couples to travel to other countries where services are cheaper but not as well-regulated. This has a knock on effect to the NHS, who pick up the cost of complicated multiple pregnancies.

Other services within the NHS are affected, too. A survey carried out by the University of Middlesex showed that 90 per cent of respondents who were unable to conceive were depressed, while 70 per cent noted a detrimental impact on their relationship. These are real people. With real feelings. The emotional effects of coming to terms with requiring IVF are devastating.

During the parliamentary “debate” it was suggested that an investigation be carried out into the provision of IVF services in England with stronger guidance to CCGs that they should be expected to comply with NICE guidelines or offer clear reason for not following.

There may soon be no ‘way in’ to Mayday Hospital for those seeking IVF treatment on the NHS

The NHS appears to see fertility services as a second-class service which is not important. It’s seen as a luxury. But infertility is not a choice made by women, it’s a recognised medical condition that requires treatment.

Some professional working couples are re-mortgaging their property to fund cycles privately. Poorer couples will be denied the opportunity to have children without the NHS. It all appears to be another instance where reduced funding is pushing more NHS patients towards private health providers.

NICE guidance is clear and fair. It doesn’t suggest unlimited cycles, it suggests three full cycles. By not adhering to these guidelines, how are CCGs demonstrating fair and equal access to treatment that is free at the point of delivery according to need? That’s part of the ethos of the NHS and it seems to be being forgotten. Blanket restrictions that do not take account of individuals’ needs are unacceptable, so what is being done about it?

And what is the point of NICE recommendations if they can be disregarded?

CCGs were set up as decisions to local services should be made as close to patients as possible, to reduce inequality and improve care quality, as different areas may have different needs and priorities It is possible for CCGs to implement the NICE recommendations on IVF – Camden does it. So what have they done, how have they managed it and what else has had to give? What can Croydon learn from them and has anyone from CCG thought about collaborating with other CCGs to discuss ideas and issues?

At the recent meeting of Croydon council’s health and social care scrutiny committee, Dr Agnelo Fernandes, the assistant clinical chair of Croydon CCG, said the cuts to IVF and other services were “only the start”. The committee referred the CCG’s decision around routine access to IVF and ICSI* to the secretary of state for health because “they are concerned about the impact on those affected, the sustainability of local health services and the historic underfunding of NHS services in Croydon”.

The buck has been passed to Jeremy Hunt. Given the consultation results in Croydon and seeing that the parliamentary debate on the subject had everyone agreeing that IVF is an important service, let’s hope Hunt makes the right decision.

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