Rationing fertility services in the NHS: A Policy Statement
The provision of specialist medical services in society is influenced by an assessment of the health needs of the population as a whole (demand), the resources allocated for the purpose (supply), and importantly the potential for health gain through medical intervention (clinical effectiveness). Rationing, whereby potentially beneficial health care may be withheld for financial or organisational reasons, presents an ethical problem that has been at the heart of state financing of medical care since the inception of the NHS. Rationing of health care resources leads to tension for providers of healthcare between a concern to benefit the maximum number of stakeholders in society and a desire to respond to the needs of individuals. Most would acknowledge that the purist view that, irrespective of cost, the best possible treatment should be available for all patients, is not attainable.
The proportion of our national gross domestic product that should be invested in the provision of state funded health care is a matter of continued political debate. The Society welcomes the recent increase in NHS funding announced by the Chancellor, and with other professional bodies would wish the trend towards equality of resource allocation throughout Europe to continue.
The consequences for patients of inadequate investment to provide universal funding for care, in any branch of medicine, are either to access alternative providers of care in the private sector, or, for those with insufficient personal resources to meet the high costs of such alternatives, denial of access to treatment. While neither of these options is desirable it is accepted that private and state funded healthcare are complementary.
It is generally acknowledged that the management of infertility represents a healthcare need and that effective treatments are now available. While these include long established treatment modalities such as ovulation induction, donor insemination and surgical treatment of endometriosis, assisted conception techniques including in vitro fertilisation are now recognised as effective interventions. If universal health care funding is unattainable, establishing justice in determining the relative merits of one form of medical treatment over another presents a problem. Commissioners of health care are required to prioritise among diverse medical areas. Robust, objective and transparent mechanisms, free of personal bias, should inform such policy decisions. It would be desirable for representation of all stakeholders in bodies making such decisions, and that they should be accountable for their actions. The Society, which includes over 900 clinicians, scientists, nurses and counsellors, and in addition has formal patient representation on committee, would welcome the opportunity to take part in any discussions with the Department of Health concerning this important issue.
Specifically with respect to infertility services, the policy of central government to devolve decisions on funding treatment to local commissioners has led to inequalities in access to care across the country. Recent surveys have highlighted the large variation throughout the country of access to NHS-funded IVF, ranging from no provision to virtually unlimited treatment. If it is accepted that not all will have access to treatment within a defined population, in the pursuit of equity and justice, agreed UK criteria should be developed and applied in assigning prioritisation among couples needing IVF. In Scotland, certain criteria, both medical (with reference to effectiveness of treatment, incorporating factors such as female age and number of treatment cycle carried out previously) and social (responsibility for any other children) have been devised and recommended by the Department of Health to Regional Health Boards. These may be a model for a national UK policy in this difficult area1.
- Department of Health in Scotland. Evidence and Equity: A National Service Framework for the Care of the Infertile in Scotland. (2000) www.show.scot.nhs.uk/publications/ME/eagiss