Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Fertility treatment – an economic blessing or burden?
- Jonathan H West (7 September 2003)
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Post code lottery- more complex than it appears
- Gaby J Tobias (8 September 2003)
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In vitro fertilisation for all
- Gillian M Lockwood (12 September 2003)
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In vitro fertilisation for all?
- Alison P Murdoch, Richard Kennedy, Mark Hamilton, Ian Cooke, Neil McClure, Richard Flemming, Umesh Acharya, Elizabeth Lenton, GIllian Lockwood ( Committee of BFS) (14 September 2003)
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Local decision-making has lead to discrimination
- Raj Mathur, Cambridge CB2 2QQ (14 September 2003)
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End the policy confusion
- Roger Worthington (MA PhD) (21 November 2003)
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Jonathan H West, Consultant Obstetrician & Gynaecologist Royal Devon & Exeter Hospital, Devon EX1 2ED
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Both the National Institute for Clinical Excellence (NICE) in their draft report (1) and Richard Ashcroft’s editorial (2) avoid the question of how we may quantify the value of in vitro fertilisation (IVF) both in absolute terms and relative to other health spending priorities. This is an issue that should be addressed, however. The potential beneficiaries of IVF are the couple being treated; the individual(s) created as a result of the treatment; and, the taxpayer. Childless couples may be disadvantaged by their distress, by social disability, and by the absence of children to help provide care and support in old age. Whilst no direct data exists to provide standard Quality Adjusted Life Year (QALY) values to these problems so far as subfertility is concerned, we may reasonably ascribe a value in the order of 0.97 based upon more general research (3) and on an assumption of ‘moderate’ distress and ‘slight’ social disability. If we allow for the sake of argument that two people are affected for up to 40 years each (Age 35 to 75) the number of QALYs resulting from successful treatment is 2.4 at an average cost of approximately £15,000 (assuming a 20% average success rate for IVF at £3,000 per treatment cycle). The £/QALY ratio for the couple alone is thus in the region of £6,250, which is more than hip replacement but less than heart transplantation. Successful treatment results, however, in the creation of new human beings who would otherwise not exist. We may reasonably add the value of their healthy life expectancy, currently approximately 67 years (4), to the equation. The £/QALY ratio now becomes approximately £215, making IVF treatment more cost effective than any other form of healthcare spending. Finally we should consider whether the creation of children to couples who want and are able to care for them is in our general economic interest at the present time. This is a complex question since on the one hand the economic value of children to a totally childless society would be enormous, whilst on the other hand there may be situations where overpopulation may be a disadvantage in the face of limited resources. Assuming for the sake of argument that our country currently is not overpopulated with children we may wish to consider that average lifetime earnings are currently £975,000 per person, of which approximately £195,000 is paid in tax (5). Leaving aside the contribution that children born from IVF treatment would make to the progress of society as the workers, health carers, sportsmen and women, artists, scientists and leaders of the future, in the event that a ‘hard-nosed’ community required the individuals who were thus created to pay for that treatment themselves over the course of their lives they would clearly be an economic benefit and not a burden to society. In view of this, and bearing in mind it’s profitability to society, perhaps a case could be made for special funding for fertility treatment separate from other healthcare expenditure. In conclusion when we read and hear of children born from IVF treatment we should not so much think ‘there’s another £15,000 gone..’, but ‘there’s another couple whose distress has been relieved and who have the opportunity to experience the love and fulfilment of children; there’s another human being who has been given the opportunity to live a life; and, there’s another person to pay the taxes for our healthcare and pensions when we retire’. 1. National Institute for Clinical Excellence. Fertility: assessment and treatment for people with fertility problems. NICE guideline, second draft for consultation. London: National Institute for Clinical Excellence, 2003. www.nice.org.uk/pdf/Fertility_Fullguideline_2ndconsultation.pdf 2. Ashcroft R. E In vitro fertilisation for all? BMJ 2003;327:511-512 (6 September) http://bmj.com/cgi/content/full/327/7414/511?eaf 3. Kind, Rosser and Williams in Jones-Lee, ‘The value of life and safety’, 1982. http://www.oheschools.org/ohech5pg3.html 4. Life expectancy and healthy life expectancy at birth: by gender: Social Trends 31. Government Actuary's Department; Office for National Statistics. http://www.statistics.gov.uk/StatBase/Expodata/Spreadsheets/D3527.xls 5. Lakin C. The effects of taxes and benefits on household income, 2001–02. Office for National Statistics. http://www.statistics.gov.uk/cci/article.asp?id=377 Competing interests: The author hopes there will be enough children in the future to pay for his healthcare and pension when he retires. |
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Gaby J Tobias, GP. Co chair City and Hackney TPCT Hackney E9 7PX
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EDITOR.
In City and Hackney, for example, there are extremely high levels of severe mental illness, ischaemic heart disease and diabetes. These conditions result in high admission rates, which must be funded. Even within these areas, we know that because of the high demand, City and Hackney patients fare worse than in less deprived areas; because of the disproportionate numbers of patients with severe mental illness, those with "lesser" conditions such as depression have comparative less access to psychiatric help than in other areas (a less publicised example of the post code lottery). City and Hackney PCT is funded at £10 million under its target allocation We have to prioritise serious medical and psychiatric conditions. It is because of this combination of high morbidity and under resourcing that we do not fund IVF, not because we place a low value upon it. I agree that differences should be allowed to flourish when they are the result of a local priority setting. However this should happen on a level playing field of resource allocation matched to need. Competing interests: None declared |
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Gillian M Lockwood, Medical Director Midland Fertility Services, Centre House, Court Parade, Aldridge, WS9 8LT
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Comments on ''in vitro fertilisation for all' The author of the editorial ''in vitro fertilisation for all' seems to me to be confusing two distinct issues. It is of course appropriate that local health care provision reflects the overall profile of the health needs of the local population. But this obvious fact by no means justifies that inference that such a question as to whether childless women with a fertility problem should be given free cycles of IVF would be appropriately decided by 'a local political process'. For in a case of this kind, democracy can easily become the enemy of fairness. Suppose that the local region in question is that part of the South Coast in which the bulk of the population are retired - the so-called 'Costa Geriatrica'. Their principle health interests and priorities would presumably lie with hip replacements and cataract surgery. Nevertheless, there is a significant number of couples in the region in which the woman is of child-bearing age and some of the couples have fertility problems that IVF could address.. Then it would surely be appropriate, in the absence of the local availability of IVF, to make arrangements with other regions in order to enable such women to get access to this treatment elsewhere, for no more than the costs of travel. But how much local 'political pressure' could realistically be brought to bear on the creation of such arrangements, where few voters had a stake in the matter, and the politicians were well aware that there was only a handful of votes to be gained in making an issue of the lack of such arrangements? In such a situation, justice itself surely calls out for exactly the kind of central planning that the author of the editorial opposes. The natural extension of Dr Ashcroft's position would be to permit selected 'enclaves' of the super fit and healthy to 'democratically' decide not to fund any health provision at all! In the UK, which is in the fortunate position of being the 4th richest nation on earth, I believe it is simply unacceptable that a significant proportion of its citizens are unable to access the relatively simple and highly cost-effective treatments now available for infertility and endorsed by NICE. Our birth rate has fallen below replacement level, we face a 'pensions crisis' due to a diminishing work force and a burgeoning retired population, and the costs in the avoidable human misery that is involuntary infertility are incalculable. At last it seems that the country in which IVF was invented may, via the NICE process, be able to access this miracle of modern medicine that offers hope and help to the childless. Let us not allow this opportunity to be squandered by a bogus appeal to 'local variation'. Dr Gill Lockwood, Midland Fertility Services Competing interests: The author is Medical Director of an Independent IVF clinic which provides NHS and private fertility treatment |
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Alison P Murdoch, Professor of Reproductive Medicine, Chair of the British Fertility Society Newcastle Fertility Cenre at Life, International Centre for Life, Newcastle upon Tyne NE1 4EP, Richard Kennedy, Mark Hamilton, Ian Cooke, Neil McClure, Richard Flemming, Umesh Acharya, Elizabeth Lenton, GIllian Lockwood ( Committee of BFS)
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Editor- It is an interesting concept that postcode prescribing is due to differences in social values rather than ignorance of the evidence (1). If so, the NICE guidelines on infertility, having endorsed the evidence supporting the cost-effectiveness of IVF, will allow us now to address the core problems about the provision of treatment for those who suffer from infertility. The lack of NHS provision is the result of the negative attitude of society to the infertile. It is the reasons underlying these attitudes that must be addressed. Ashcroft is correct to say that politicians should be wary about making reproduction a major theme of their politics. Politicians have tried before to control the reproduction of an individual, with disastrous consequences. This argument applies both to the national politicians and to local decision makers in the NHS. Financial eugenics, the consequence of only allowing IVF to those who can afford the fees, is no more acceptable from a PCT than central government. The choice to reproduce or not must remain with the individual. Society supports the decision of individuals to control their own reproduction and allow them to have children who are wanted, when they want them. Society expects and the NHS provides contraceptive, sterilisation and termination of pregnancy services to all. Thus there is no logic to denying a family to those who need medical help to achieve it. Most readers will have used NHS resources to control their reproduction at some time. 1 in 6 will have needed help to conceive and most will have had to fund treatment themselves. Society needs to hear the voices of those who have suffered the torments of infertility. Let local political accountability be based on equality of their respect and rights. 1. Ashcroft R. BMJ 2003;327: 511-512 Competing interests: None declared |
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Raj Mathur, Locum Consultant Addenbrooke's Hospital, Cambridge CB2 2QQ
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Dear Sir Ashcroft 1 is right to point out that whether or not fertility treatment is funded by the NHS is essentially a political decision. He is also right to point out that NICE is not mandated to, and does not attempt to, settle questions on any basis other than clinical effectiveness. However, his prescription for leaving decisions regarding funding fertility treatment to a mythically accountable ‘local’ level is a recipe for perpetuating discrimination and lack of accountability. Local variation in NHS fertility provision is already responsible for gross discrimination and distortion in service provision that can only be overcome by a sensible setting of priorities at a central level. Current methods of determining funding priorities are capricious and have unfair consequences, as demonstrated by the existence of a post-code lottery in respect to fertility treatment. It is partly as a result of the lack of accountability at the local level that the issue of access to fertility treatment is now on the national political agenda. In this situation, it falls upon the likes of Ashcroft to show how equity and fairness would be better served by current methods of ‘local’ accountability than by centrally peer-reviewed and clinically effective advice. Either the NHS as a whole subscribes to these basic concepts or we might as well drop the 'National'. Ref Richard E Ashcroft In vitro fertilisation for all? BMJ 2003; 327: 511-512 Competing interests: The author works in an NHS Reproductive Medicine Unit |
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Roger Worthington (MA PhD), Lecturer in Medical Law and Ethics St George's Hospital Medical School, London SW17 0RE
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The guideline adopted a baseline cost (including drugs and associated health services) of £2771 per cycle of IVF. Given a total of 25,273 cycles (using all forms of assisted conception) started in 2001/2, substantial amounts of money will need to be allocated in order for the NHS to fund these treatments in full. At present some couples are unable to afford the most effective treatment and provision of subsidies by fertility clinics (with funds coming from fees charged to private paying patients) is no more an ethically sustainable policy than selling spare eggs in exchange for funded cycles of IVF. A rights-based claim to NHS fertility treatment is a matter for debate, and the right to found a family (Human Rights Act, 1998) may not extend so far as to guarantee access to assisted reproductive technology. However, unduly restricted NHS funding for fertility treatment is nonetheless discriminatory against infertile or subfertile couples, and substantial variations in service provision across England and Wales demonstrate lack of equity. While it would be discriminatory for other types of treatment to be restricted as a result of implementing the guideline (taking money from one type of provision to fund another) questions of who will be responsible for guideline implementation must be made clear. A decision on funding could negatively impact on service provision in general from overlooking such concerns. Ashcroft raises the issue of equality, and in certain circumstances he sees evidence of local variation as “a sign of health not disease”. This contrasts with the Expert Advisory Group on Infertility Services in Scotland (1999), which quite reasonably says that “it is unacceptable that couples living in different health board areas [of Scotland] have varying access to NHS IVF services”. A debate over national standards of service provision versus local autonomy in decision-making remains open, and even if details of implementation are subsequently developed at local level, confusion over funding for fertility treatment will surely remain in the absence of nationally agreed public policy. The current guideline focuses on techniques relative to clinical efficacy and the likelihood of a successful outcome resulting in a live birth; while treatment decisions are a matter of clinical judgment and agreement between a woman and her clinician, it restricts autonomous choice if clinical specialists recommend treatment not locally available on the NHS. While some major clinics attached to University Hospitals offer both fee paying and non fee-paying services, few centres are exclusively NHS funded, and while NICE ostensibly is independent of government, guidelines are capable of influencing health policy. Pressure for approved treatments to be made available on the NHS will build quickly if/when a decision is taken to implement NICEs recommendations. Setting eligibility criteria for fertility is a form of rationing, and there is a common sense argument in favour of gaining maximum utility from a given expenditure in terms of costs per live birth. While patient expectations are often unrealistically high and may need to be tempered by a sense of realism, the need for a clear, consistent public policy on access to fertility treatment has never been stronger. Such a policy could provide a more equitable remedy for the disparities that exist in terms of distribution of resources and accessibility of publicly funded fertility treatment. ·NICE guideline, second draft for consultation. London: National Institute for Clinical Excellence, 2003 (p.267) ·HFEA Press office Facts and Figures 2001/2002 http://www.hfea.gov.uk/PressOffice/Factsandfigures ·BBCi Health News Fertility clinic in egg sharing row 8 May, 2003 http://news.bbc.co.uk/1/hi/england/london/3012321.stm ·Human Rights Act [1998 ] Schedule 1, Article 12 ·HFEA Press office Facts and Figures 2001/2002 ·News roundup: One in three doctors don’t tell patients about services they can’t have BMJ 2003;327:123 ·HFEA Patients’ Guide to Infertility Clinics 2002 http://www.hfea.gov.uk/HFEAPublications/PatientsGuides Competing interests: None declared |
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