1.  It was with great interest that I read the terms of reference of the Health Select Committee's inquiry into health inequalities and would like to take this opportunity on behalf of the National Infertility Awareness Campaign (NIAC)[252] to respond to them.

  2.  I have focused comments specifically on the following aspect of the inquiry's terms of reference:

The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas, eg taxation, employment, housing, education and local government.

EXECUTIVE SUMMARY

  3.  Infertility remains a key example of health inequality in the NHS. Although positive steps have been taken to improve access to NHS funded infertility treatment, considerable variation continues to exist and patients' ability to access treatment often depends upon where they live.

KEY POINTS

  4.  NIAC is an umbrella organisation, established in 1993 with the support of a wide range of organisations involved in the field of infertility to campaign for fair and equal access to all those with an established clinical need to a full range of infertility treatment on the NHS.

  5.  Around one in six couples seek specialist treatment for fertility problems, and infertility can have a profoundly distressing and devastating impact. However, excellent results can be achieved in treating infertility if patients are rapidly investigated and referred for appropriate treatment. Unfortunately, patients have traditionally faced considerable inequality of access to treatment on the NHS, resulting in many having to resort to privately funded treatment.

  6.  NIAC therefore welcomed the publication in February 2004 of a clinical guideline by the National Institute for Health and Clinical Excellence (NICE), which aimed to address the inequalities in access to NHS funded treatment for infertility. At the time of its referral to NICE, the Government outlined its intention for the guideline to "help ensure that in future, infertile couples get fairer, faster access to clinically, cost effective and appropriate treatments"[253].

  7.  Amongst other recommendations, the guideline stated that three full cycles of in vitro fertilisation (IVF) should be made available on the NHS to all those meeting agreed clinical criteria. Upon its publication, the then Secretary of State for Health, Rt. Hon Dr John Reid MP, asked Primary Care Trusts (PCTs) to make at least one full cycle of IVF available to all those eligible by April 2005, with the expectation of progress being made towards full implementation of the guideline in the longer term[254].

  8.  Despite the publication of the guideline and the Government's announcement there continues to be considerable variation in provision of, and access to, treatment around the country. This is evident in terms of the number of cycles funded by PCTs, and whether those cycles include frozen embryo transfers (FET) as recommended by NICE. The large majority of PCTs still have not implemented the guideline's recommendation for three full cycles of IVF treatment. Some PCTs fund two cycles, most of them fund one and over the last couple of years, a number have suspended funding altogether.

  9.  There is also significant variation in the range of eligibility criteria used by PCTs for access to IVF treatment. For example, the female age range applied by PCTs can vary from the 23-39 years recommended by NICE to 34-39 years in some parts of the country. PCTs also vary in terms of whether previous treatment or previous children are considered an eligibility criterion for NHS funding[255].

  10.  In Scotland, Wales and Northern Ireland, guidance on the provision of NHS funded infertility treatment was accompanied by centrally set eligibility criteria. NIAC welcomed these efforts to ensure that patients received equal access to treatment, regardless of where they lived. However, in England, PCTs are able to set their own eligibility criteria for access to NHS funding, over and above the clinical criteria recommended in the NICE guideline, which has perpetuated the inequality of access.

  11.  A likely move towards single embryo transfer (SET) as part of a national strategy recently announced by the Human Fertilisation and Embryology Authority (HFEA) to reduce the number of multiple births from IVF, has now made full implementation of the NICE guideline of even more importance, both in terms of funding three full cycles of IVF, and in ensuring that a full cycle includes the freezing and replacement of suitable embryos not replaced in a stimulated IVF cycle, as recommended by NICE.

  12.  In October 2006, an independent expert group set up by the HFEA to look at reducing the number of multiple births from IVF recommended the introduction of SET for appropriate patients. NIAC supports this recommendation as a means of reducing the risks to the health and welfare of both mother and child that multiple births present. However, the group also concluded that failure to implement fully the NICE guideline, and the consequent lack and inconsistency of NHS funded IVF, was the single greatest obstacle to its introduction in the UK[256].

  13.  Following the HFEA's public consultation on this issue, it called for multiple birth rates to be reduced to 10% following a 3-year national strategy. In announcing the development of the strategy, the interim Chair of the HFEA highlighted the need for PCTs to understand the connection between reducing multiple births and access to IVF when making funding decisions.[257] NIAC welcomed the HFEA's response as it is much more likely that patients will accept a move to SET if they have access to the three cycles of IVF, including FET, recommended by NICE. If a PCT is only funding one cycle, without FET, it is understandable that patients may be unwilling to accept a move that may reduce the chances of that one cycle being successful.

  14.  The Department of Health is currently funding a project with Infertility Network UK, a member of NIAC, to help improve access to infertility treatment by encouraging implementation of the NICE guideline. As part of this project, the Minister wrote to the NHS in July 2007 to clarify NICE's definition of a full cycle, which includes the freezing and replacement of suitable embryos not replaced in a stimulated IVF cycle.

  15.  In response to a survey carried out as the first stage of the project[258], which highlighted different interpretations of what constituted full implementation of the NICE guideline, the Minister also reminded PCTs of the recommendation for three full cycles of IVF to be made available and called for them to move towards providing this level. The letter also announced that the Department of Health would begin monitoring IVF provision across the country and that the project would be extended to include developing standardised eligibility criteria for PCTs to use[259].

  16.  NIAC welcomes these steps and is keen to ensure that the tools developed from this project are used by PCTs to improve provision. It would particularly call for standardised eligibility criteria to be supported centrally to alleviate the current inequality of access. Further sustained action is also needed at both the national and local level to ensure real progress towards implementation of the guideline. NICE will be considering in early 2008 whether to review the guideline, yet it is still far from being implemented in full and patients still do not have equality of access to treatment across the country.

  17.  NIAC is grateful for the opportunity to respond to the Committee's inquiry and hopes that its comments will be taken into consideration.

January 2008

253   Department of Health press release, Working Towards Ending the Postcode Lottery of Infertility Treatment, 30th November 2000. Back

254   Department of Health press release, Health Secretary welcomes new fertility guidance, 25th February 2004. Back

255   Department of Health publication, Primary Care Trust survey of provision of IVF in England, 2006, 23rd October 2007. Back

256   One Child at a time, Report of the Expert Group on Multiple Births after IVF, 18th October 2006. Back

257   Speech to the British Fertility Conference, 4th December 2007. Back

258   Department of Health publication, Primary Care Trust survey of provision of IVF in England, 2006, 23rd October 2007. Back

259   NHS Infertility Treatment- Dear Colleague Letter, 31st July 2007. Back