NHS Fertility Services

Baroness Blackwood of North Oxford Excerpts

Thursday 19th January 2017 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (Nicola Blackwood)]

It is a pleasure to serve under your chairmanship, Mrs Gillan. I congratulate the hon. Member for Birmingham, Selly Oak (Steve McCabe), my right hon. Friend the Member for Wantage (Mr Vaizey) and the right hon. Member for Carshalton and Wallington (Tom Brake), who is not in his place, on securing this important debate. I am grateful for the opportunity to discuss NHS fertility services. This has been a moving debate and, on behalf of the Government, I recognise at the outset that infertility is a serious condition, affecting a growing number of people: women and men and same-sex couples. I personally thank all of those who have allowed their stories to be shared today. They remind us powerfully of the distress that infertility causes. The value of their being shared in the debate cannot be overstated.

It is important to remember that those stories are not isolated cases. As hon. Members are well aware, fertility problems are estimated to affect one in seven heterosexual couples and, for couples who have been trying to conceive for more than three years without success, the likelihood of pregnancy occurring in the following year is 25% or less. We should keep those figures in our minds.

As my right hon. Friend said, infertility can and does have a powerful and lasting impact on the quality of life of those affected. Research has shown that there can often be psychological effects, as powerfully described in the debate, for both men and women suffering from fertility problems. It can cause stress and it puts pressure on relationships, primarily between the couple themselves but also on relationships with family and friends. It is therefore important that the NHS provides access to fertility services for those who need clinical help to start a family.

The availability of NHS fertility treatment is and always has been a matter for local determination. As my right hon. Friend said, these are not easy decisions to make, but we expect them to be made fairly. Decisions on the level of service provision are underpinned by clinical insight and knowledge of local healthcare need. That has been the case since the introduction of the purchaser-provider split in the 1990s, and today that determination is, as we all know, made by CCGs, which are clinician-led and have a statutory responsibility to commission healthcare services that meet the needs of their whole population, reducing inequalities and improving care quality.

While provision of services will, by necessity, vary—for example, the health needs and priorities of the population of Birmingham will not be the same as that of Bournemouth—it is right that those difficult prioritisation decisions are led by clinicians who know their patients and local areas best rather than being made centrally. The Government have made it clear that blanket restrictions on any healthcare treatment—including fertility services—are unacceptable. Where a service is not routinely commissioned, clinicians can still make individual funding requests for their patients when a clinical case can be made and if treatment is likely to provide significant benefit. It is the role of NHS England to ensure that CCGs are not breaching their statutory responsibility to provide services that meet the needs of their local population and to take action if such breaches do take place.

[Steve McCabe]

I recognise what the Minister says about this being an issue for local determination. However, does she agree that it does not make sense to use moralistic criteria to ration the provision of services, which—as in the example I cited in Birmingham—is then put to a public poll that produces an inconclusive result on a very low turnout? Surely that is not the kind of local determination we want. Is that not something that NHS England should act on?

[Nicola Blackwood]

The hon. Gentleman gave a very good opening speech in which he raised some points that I will comment on. The quality of commissioning of fertility services is one of those points, and having regard for guidance already in place to guide local commissioners in commissioning fertility services is a point on which I am about to comment. He has anticipated my speech as only a seasoned politician can.

NICE first introduced its fertility guidelines in 2004. As with all clinical service guidelines, they have never been mandatory. Successive Administrations have supported the principle of locally determined implementation of key recommendations of the guidelines, because decisions about local services should be made as close to patients as possible by those best placed to work with patients and the public in their area to understand their needs. However, it is sadly the case that implementation has been variable over the years, particularly with the provision of three IVF cycles for qualifying couples, as we have heard. As the hon. Member for Birmingham, Selly Oak and the shadow Minister rightly said, the 2016 Fertility Fairness survey showed that just 16% of CCGs provided the recommended three cycles of IVF, with 22% providing two, 60% providing one and 2% providing no IVF funding at all.

I understand that commissioners in some areas are undertaking their own evidence reviews, as the hon. Member for Birmingham, Selly Oak said, to determine whether their CCG should offer IVF. I take this opportunity to say that that is unnecessary. NICE was established for the specific purpose of reviewing the available clinical and scientific evidence of a treatment’s effectiveness and, working with a wide range of stakeholders, to make recommendations based on that evidence about services that should be available to all within the NHS. NICE guidelines for fertility services are robust and fit for purpose, and there is no need for them to be second-guessed by commissioners.

The hon. Gentleman also raised NICE guidelines for same-sex couples. NICE guidelines seek to offer heterosexual and same-sex couples the same access to investigation and treatment for fertility problems, the criterion for which is a failure to conceive over a set period of time. NICE sets that criterion to ensure that NHS funding is available for donor sperm for female same-sex couples, or surrogacy arrangements for male same-sex couples, on the basis that they are medically sub-fertile, not that their childlessness is owing to the absence of gametes from the opposite sex—sperm or eggs.

Access to NHS-funded investigations is commissioned in female same-sex couples who fail to conceive after six cycles of artificial insemination within a 12-month period. NICE recognises that same-sex couples could be disadvantaged, because they may have to pay for artificial insemination before they can be considered for NICE assessment and possible treatment. NICE considers six cycles to be equivalent to the 12-month period of unprotected intercourse required of heterosexual couples before they are offered investigation for fertility problems. Same-sex couples are offered access to professional consultation and advice in reproductive medicine before they embark on attempts to conceive, to ensure that they are informed about appropriate and safe self-funding attempts. I can tell the hon. Member for Birmingham, Selly Oak that NICE is due to review its fertility guidelines this year, and he may wish to write to NICE’s guidelines review team to offer his views on the issue. The Department of Health will certainly be doing so.

On the implementation of NICE guidelines, I commend CCGs, such as Camden, Oldham and others that have been mentioned, that have implemented the NICE fertility guidelines in full and continue to offer three IVF cycles to qualifying couples. That shows it is entirely possible for CCGs to implement NICE’s IVF provision recommendations. It was disheartening to learn from the Fertility Fairness survey that access to IVF treatment on the NHS has been reduced in so many places, and it is deeply disappointing that some CCGs have stopped routinely commissioning it. I strongly encourage all CCGs to implement the NICE fertility guidelines in full, as some CCGs are successfully doing.

[Justin Madders]

The Minister has correctly identified that some CCGs are not providing any treatment at all. Does she think that blanket policy should be dealt with?

[Nicola Blackwood]

I am about to go on to work that we are doing to assist CCGs with better commissioning, including giving them advice on pricing, which the shadow Minister mentioned. Perhaps he will allow me to do that; I think it will be enlightening for him.

Work is under way to assist CCGs in better commissioning fertility services for their local community. It is right that we do that. My right hon. Friend the Member for Wantage was correct—the cost of IVF is falling, but not all CCGs are benefiting from that. We know that the prices that fertility clinics charge CCGs for an IVF cycle vary, and that some CCGs are not contracting in the most effective way.

The Fertility Fairness survey reported that the price being charged by service providers for an IVF cycle varied across the country, from around £2,000 at the bottom end to more than £6,000 at the top, although it is not clear what all of those treatment cycles involve. The Department of Health, NHS England and professional and stakeholder groups are working together to develop benchmark pricing for fertility services to ensure that CCGs get the best value for their money. That is obviously the first step to be taken before NHS England’s longer term work towards developing a national tariff, which my right hon. Friend called for.

In addition to that initiative, the national fertility regulator—the Human Fertilisation and Embryology Authority—is developing commissioning guidance that aims to improve the quality of commissioning, for example by encouraging greater use of single embryo transfers where appropriate for a patient. That does not reduce the chance of a woman having a baby but significantly reduces the incidence of multiple births, with their attendant risks and complications for mothers and their babies. NHS England has agreed to disseminate and promote that guidance to all CCGs in England.

Those approaches are intended to raise the level of knowledge and expertise within CCGs to ensure that they are able to commission services appropriately in what is a specialist area, exactly as my hon. Friend the Member for South West Bedfordshire (Andrew Selous)—who is no longer in his seat—called for. It would also be helpful for CCGs to pool their resources and expertise and collaborate more with each other to get a better deal for their patients. That has happened in the north of England, where members of two commissioning collaboratives are able to offer three IVF cycles to qualifying couples.

As I hope has been clear, it is the Government’s view that infertility is a serious medical condition. Those suffering from infertility who meet the criteria in the NICE fertility guidelines for NHS-funded treatment should be able to seek that treatment. We do not agree that clinical infertility should not be part of a comprehensive national health service. Reflecting on the strength of feeling expressed today, I will be writing to NHS England to ask that it communicates clearly to CCGs the expectation that NICE fertility guidelines should be followed by all.

The Department of Health, NHS England and professional and stakeholder groups will redouble efforts to develop the benchmark pricing for fertility services, which, as I have said, is a precursor to NHS England introducing a national tariff. NICE will continue with its review of fertility guidelines this year. I hope that series of actions demonstrates just how seriously the Government take this situation, and leaves all those watching the debate confident of our commitment to finding practical solutions to this serious problem.