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Implementing the NICE guidelines on the provision of
infertility treatment in the UK 2004:
The potential role of the private sector.
Peter R Brinsden FRCOG
Medical Director
Bourn Hall Clinic
Cambridge, UK
Tel: 01954 719111
Fax 01954 718826
E-mail:
peter.r.brinsden@serono.com
Since the earliest days of assisted reproductive techniques (ART), the
majority of patients requiring ART in the UK have been treated in the
private sector. Following the birth of Louise Brown in 1978, Patrick Steptoe
and Robert Edwards, the pioneers of in vitro fertilisation (IVF), were
unable to obtain funding from the National Health Service (NHS),
universities, or the Medical Research Council to continue to treat patients
requiring IVF, or to continue their research.
Bourn
Hall Clinic, the world's first specialist ART centre, was therefore founded
by Steptoe and Edwards in 1980, funded entirely privately. Ever since then,
the majority of ART cycles in the UK have been carried out on patients who
have had to fund their own treatments. The limited NHS funding that has been
available has been sporadic and has only accounted for 15% - 20% of the
total IVF cycles performed in the UK each year.
Since 1992, Bourn Hall Clinic has engaged in a number of different
contracts with Health Authorities and Primary Care Trusts, and currently has
four NHS contracts and one Channel Island contract. Each sets out different
criteria for the selection of couples for treatment. Female age, male age,
infertility diagnosis, number of existing children, duration of
relationship, time living in area, smoking habits and female body weight
have all been used with different emphases as inclusion or exclusion
criteria.
An end to the "postcode" lottery
Therefore, since Bourn Hall Clinic cares for both private and NHS funded
patients, the NICE guidelines1, which were published in early 2004, were
warmly welcomed. If implemented, they should put an end to the unfair
'post-code lottery' system that has existed for so long in the UK, whereby
couples may or may not receive NHS funding, depending entirely on where they
live.
One of the recommendations in the NICE report is that IVF treatment
should be provided, and should consist of a maximum of three complete
'fresh' cycles. However, the cost implications were considered to be too
great for this to be implemented all at once, and the government therefore
recommended that only one cycle per couple should be funded initially, with
the possibility that this might be increased to the recommended three cycles
in time.
Limiting the funding to only one cycle has disappointed many couples and
infertility support groups, and does severely limit a couple's chances of
success. There is also no guarantee that all Primary Care Trusts (PCTs) will
follow the NICE and the government's recommendations.
Specific recommendations
The specific recommendations of NICE are that couples should be offered IVF
treatment if they meet the following criteria:
- The woman is between 23 and 39 years of age and there is an
appropriate diagnosis of infertility of any duration, or unexplained
infertility of at least three years' duration, including mild
endometriosis and mild semen abnormality.
Or:
- If the woman is younger than 23 years of age and there is an
absolute indication for IVF (for example tubal blockage, very poor semen
quality or prior treatment for cancer).
Private clinics can bid successfully for NHS contracts
During the past 10 years, several private clinics have successfully bid for
NHS contracts. If the number of patients requiring IVF treatment greatly
increases within a comparatively short time, it is proposed that the private
sector should take up the slack and bid competitively to provide cost
effective treatment for NHS funded patients. When awarding contracts, PCTs
should be wholly driven by good evidence of clinical effectiveness, cost
effectiveness and the provision of quality services to their patients.
Cost effective treatment
At Bourn Hall, a careful analysis of the costs of providing treatment is
made and a 'sensible' bid is made for individual contracts, bearing in mind
the different criteria stipulated by the PCT. The results of treatment are
audited regularly and a detailed breakdown of treatment outcomes is
presented to the PCT at six-monthly meetings, together with the results of
patient satisfaction surveys. The contracts may be renewed or withdrawn by
the PCT at the end of each financial year.
In addition to the NHS contracts, Bourn Hall Clinic has a number of
"Satellite IVF" and "Transport IVF" arrangements. Close relations exist with
four hospitals, two providing private treatment only and two providing both
NHS funded and private treatment.
There is also a satellite arrangement with Addenbrooke's Hospital, with
close collaboration between the two teams, who are able to provide "seamless
care" for their patients. Regular meetings are held with the satellite and
transport clinics and all results are audited regularly. All clinics
participating in satellite or transport arrangements abide by a mutually
agreed set of protocols.
Bringing the UK into line
The UK has been a world leader in the development and practise of ART over
the last 26 years, but it has fallen woefully behind the majority of its
European counterparts in the provision of state funded advanced fertility
treatments. In the majority of European countries the health service funds
two or more ART cycles per couple, and funding is consistent across the
country, in contrast to the patchy, 'postcode lottery' service which
currently is provided in the UK. Implementation of the NICE guidelines will
begin to redress this unfair situation.
Demand for IVF treatment will increase
The NHS will be unable to cope, at least in the first few years, with the
increase in demand for treatment. The private sector can and should be
allowed to help to satisfy this demand. Evidence of clinical and cost
effectiveness should be the primary factors on which the decision to
allocate contracts should be made. Other issues, such as quality of care,
complaints procedures, the incidence of complications and the facilities
provided by the clinic should also influence the decision to award
contracts.
Private ART clinics which wish to tender for NHS contracts should
therefore be allowed to do so on an equal footing with NHS or University
clinics.
Reference
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