Thursday 19 January 2017
[Mrs Cheryl Gillan in the Chair]
NHS Fertility Services
I beg to move,
That this House has considered decommissioning of in vitro fertilisation and other NHS fertility services.
It is a pleasure to serve under your chairmanship today, Mrs Gillan.
I am grateful to the Backbench Business Committee for granting this debate; to the right hon. Members for Carshalton and Wallington (Tom Brake), and for Wantage (Mr Vaizey), for their support in securing it; and to the many other Members who are either here today or who have indicated their support for a debate on IVF. Change is urgently needed in this area, and we have broad, cross-party support for such change.
I know that it is not customary, Mrs Gillan, to refer to the Public Gallery during debates such as this one, but perhaps I can just say in passing that I am told that a number of people have travelled here today because of the importance they attach to this issue, and because of their strong feelings that what is going on is not fair and needs to change. It is through listening to their experiences that I have begun to understand the extent to which the present arrangements are not working.
Does the hon. Gentleman agree that, rather than imposing a postcode lottery on our constituents by withdrawing these services, the areas under financial pressure need to become more efficient and to look at how other areas manage their health systems better to make efficiencies, so that in vitro fertilisation can be provided everywhere?
I certainly agree with the hon. Gentleman about a postcode lottery; there is a massive variation in service, so we must strive to achieve a cost-efficient system that is genuinely national in the way it is delivered. I agree with that absolutely.
This debate is about IVF and related services. At a time of so much concern about the NHS generally, the debate could easily drift towards becoming a series of questions about other aspects of the NHS, but I am clear that we asked for this debate to raise concerns associated with those who need treatment for infertility issues.
Infertility is a problem that does not get a lot of Government or parliamentary attention; in fact, it was not debated at all in the previous Parliament. Yet we know that it is an issue that affects one in six couples in the UK and is the second most common reason for a woman to visit her GP. The problems of infertility are recognised by the World Health Organisation as a condition for which medical treatment should be provided, but that is not how we approach the matter today in England.
I am immensely grateful to my constituent Louise Jackson for bringing this issue to my attention and for giving me permission to share some of her experience with people today. Louise and her partner have been together for more than 13 years and have been trying for a baby for nearly six years. After tests confirmed that they would need IVF treatment, they were refused it because Louise’s partner already had a child, as a result of a previous relationship in 1975. That child is actually older than Louise herself, who has said:
“Anyone who is experiencing fertility problems will understand the agonising pain and upset it brings on a daily basis. The fact that we have been refused treatment on the NHS just adds to the anguish. We cannot express enough how hard it is to not be able to have children naturally, never mind being faced with the fact we’ve been saving for years for the thousands needed for this treatment. I hope one day these laws will be changed for couples like us and others in the near future.”
My information is that four clinical commissioning groups in England—Mid Essex, North East Essex, Basildon and Brentwood, and South Norfolk—have already decommissioned their assisted conception services, essentially as a cost-saving measure. Also, more than one in 10 CCGs in England are currently consulting on reducing or entirely decommissioning NHS fertility treatment. That means that more than 60 Members of Parliament represent seats where the provision of IVF services is at risk.
The guidelines produced by the National Institute for Health and Care Excellence are fairly clear on the provision of IVF services. NICE recommends that all those women who are eligible for IVF should have access to three full cycles of IVF if the woman is aged under 40, and in 2013 it updated its guidance to recommend further that women aged between 40 and 42, and who meet some additional criteria, should have access to one full cycle.
Fertility Fairness is an umbrella body that has the support of several organisations, including the Royal College of Nursing, the Association of Clinical Embryologists, the British Fertility Society, the National Gamete Donation Trust and the Miscarriage Association. In 2016, it undertook an audit of every CCG in England and found that only 16% of CCGs offer three cycles of IVF, which is the NICE recommendation. That was down from 24% in 2013, while the number of CCGs offering just one cycle of NHS-funded IVF treatment has leapt to 60%. The Minister is on record as saying that she finds the decommissioning of such services “unacceptable”, so she will not be surprised if I ask her what she plans to do in response to these figures.
According to NICE, a full cycle of IVF treatment should include one round of ovarian stimulation and the transfer of all resultant fresh and frozen embryos, but only four out of 209 CCGs comply with the NICE definition of a “full cycle”. As a result, in many parts of England, these efforts to provide IVF on the cheap are—perversely—wasting resources, because this incomplete offer is rarely successful and compromises the cost-effectiveness of IVF as a treatment. It is a bit like giving less than the recommended dosage of any other drug or treatment.
As I have said, NICE offers guidance on age appropriateness for IVF. However, without being required to offer any kind of explanation, some CCGs have lowered the maximum age for IVF to 35; others have introduced non-medical criteria, such as refusing couples treatment if one of them has a child from a previous relationship, as happened in the case of my constituent, Louise Jackson; and apparently even more criteria are applied for same-sex couples, including a requirement to demonstrate that they have already paid privately for six cycles of treatment before they can be considered by the NHS. Those requirements do not look like medical criteria to me; they look like crude, discriminatory rationing, based on pseudo-moralistic prejudices.
In Birmingham, CCGs justify their approach by testing their proposals via public consultation, and in 2014 a consultation covering the criteria for eight CCGs across the west midlands was undertaken. Of the 351 people who responded, 40% were against providing IVF to a couple where one party has a child from a previous relationship; 40% disagreed with that view; and 20% did not know. Nevertheless, those proposals are now the criteria that must be met. I cannot imagine such a crude approach being adopted for determining treatment eligibility for any other medical condition, but that of course is part of the problem.
Too many people think, in defiance of the World Health Organisation, that it is a lifestyle issue and not a medical condition. That is not helped by the fact that the Department of Health merely asks that CCGs “have regard to” the NICE guidelines. This recognised medical condition can have a number of related impacts. If left untreated, it can result in stress, anxiety, depression and the breakdown of relationships. A recent survey of almost 1,000 people with infertility problems conducted by Middlesex University found that 90% of respondents reported feeling depressed and 42% reported feeling suicidal, which was up from 20% when a similar study was conducted in 1997. Some 70% reported a detrimental impact on their relationship, and 15% said that it had led to the break-up of their relationship.
The debate is not about statistics, though; it is about real people and the devastating impact that being denied treatment for infertility problems can have on their lives. On Monday afternoon, I took part in a digital debate with many members of the public, and they helped contribute to our debate today. Hundreds of people shared their experiences. I cannot name them all, but I would like to take this opportunity to thank them for their contributions. I want to briefly share just a few examples that illustrate the kind of problems that mean we need to see some significant change in the delivery of this service.
Kelly Da Silva from south Derbyshire said:
“This is such an important issue for me, the anxiety and depression caused as a direct result of infertility and involuntary childlessness has affected every aspect of my life and caused me to leave a successful 12-year teaching career. The emotional and social impacts are absolutely devastating.”
Becky Thomas is from Hertfordshire, and comes under the direction of a Cambridgeshire CCG. She said:
“My local CCG cut the amount of cycles they offer from three down to one and are considering getting rid altogether. I live in one area that actually offers three full cycles however I come under a completely different CCG. It shouldn’t be a postcode lottery. It’s not a lifestyle choice. It’s a medical condition.”
Erin Nina Desirae from Sheffield said:
“I am in a same-sex marriage. My wife and I have been together for six years and have always talked about having children. We assumed that the law in this country would support us and enable us to try for a family with help from the NHS. Unfortunately, we were surprised and hurt to find that same-sex couples are not offered fertility treatment on the NHS until we have first self-funded at least six cycles ourselves. Whilst a heterosexual couple can receive NHS treatment after two years of trying to conceive. This feels like discrimination. Why should we be treated differently?”
What of the costs? Evidence suggests that many of the decommissioning and service reduction decisions are driven largely by budget considerations. Reports show that the cost to CCGs of commissioning one cycle of IVF can range from £1,300 to £6,000. It varies dramatically across the country. For example, it is much cheaper in Newcastle than it is in Birmingham, without any obvious explanation. What kind of way is that to run a health service and provide a vital treatment? Is it not a classic example of the fragmentation of the NHS that many predicted would follow the Lansley reorganisation?
In England, more than 200 CCGs are responsible for setting their own criteria and commissioning their own IVF services. To make matters worse, research suggests that the high cost of IVF in the private sector is forcing people to travel to such countries as the Czech Republic, where IVF treatment is far cheaper. The problem is that IVF is not anywhere near as well regulated in those countries as it is in the UK. As a direct result of reducing services in the UK, the NHS is being saddled with the high cost of complicated multiple pregnancies and births and other postnatal issues. There is also the additional cost to mental health services, which I touched on earlier. [Interruption.] As you can see, Mrs Gillan, I have successfully transposed a page of my notes. I hope you will bear with me for one second.
Mr McCabe, this sort of thing happens to people all the time. We will bear with you.
I cannot believe I have done it, but I am extremely grateful for your patience.
As I was saying, the costs of people having to go abroad fall on the NHS, and that leads to further complications that may impact on our mental health services.
In the course of my speech, I have concentrated on the impact on women, but the issue does not solely affect women. It affects couples, same-sex couples and men. I understand that CCGs that are cutting back on IVF generally are also cutting back on ICSI—I am told that it stands for intracytoplasmic sperm injection and is the most common treatment for men with infertility problems—and I worry that men’s experiences of infertility are not fully appreciated. They may also suffer hidden trauma and stress as a result of their problems. I am grateful to Richard Clothier from Dunstable who said:
“The emotional strain served to us when our infertility was confirmed was absolutely horrific and debilitating. However, this does not touch the sides when compared with the mental health deterioration we endured from the precise point at which we learned our entitlement has been slashed by two thirds. Luton, in the same county, has three cycles, the rest of us in Bedfordshire get just one cycle.”
What do I hope to get from this debate? I hope that the Minister, by the time she has had a chance to reflect on all the contributions and the terrible experiences of so many people, will have heard enough to be convinced that she should set up an investigation into the provision of IVF services in England. I hope she will be persuaded to offer much stronger guidance to clinical commissioning groups that in all normal circumstances they should be expected to comply with NICE guidelines and at the very least offer a clear and unambiguous explanation for their reasons when they choose not to follow NICE guidelines. I hope she will be persuaded to look again at the case for setting a national tariff for the provision of IVF. It is simply ludicrous that when NHS resources are so stretched, as the hon. Member for South West Bedfordshire (Andrew Selous) said earlier, the same treatment can vary in price between £1,300 and £6,000. Those who have suffered with this condition feel they have been ignored and mistreated for far too long. They are entitled to expect that we will now act to address the problem.
I am grateful for the opportunity to speak in this important debate under your chairmanship, Mrs Gillan. I thank the hon. Member for Birmingham, Selly Oak (Steve McCabe) for securing it. I appeared with him in front of the rather intimidating Backbench Business Committee, but thanks to his eloquence and advocacy we now have time to raise this issue in the House. Hon. Members frequently table questions about IVF, but I do not recall when we last had a debate on the subject. It is right that we have the chance to raise the issue, which has frequently crossed my desk since I was lucky enough to be elected to represent the Wantage constituency. Like the hon. Gentleman, I will talk about some of the cases that have come across my desk. They will sound very similar to those that he raised, because couples not being able to have children and not being able to access the treatment that can help them have children has a huge emotional and health impact on them.
As the hon. Gentleman said in his eloquent opening speech, which covered all the issues, it is important to stress that infertility is a disease. Choosing to have children—I hate to put it like this—is not a lifestyle choice; it is a fundamental choice that many people are lucky enough to be able to make. People who are not able to conceive children suffer from a disease, and I think it is therefore incumbent on the national health service to help combat the impact of that disease, as it does for many other diseases. This issue is much more prevalent than people realise: it affects one in seven couples in the UK. I am sure everybody in this House knows people who have been affected directly, and our constituents contact us about it. As the hon. Gentleman pointed out, it is the second most common reason why women visit their GP.
We have also heard how more and more clinical commissioning groups are now disinvesting in NHS fertility services. The signals from NICE, the Government and the CCGs themselves clearly show that fertility services are seen as second-class NHS services that do not rank alongside other, more important services. We in this House know from the many debates we have had, and not least from the huge increase in the profile of and focus on mental health services, that treating something as a second-order issue stores up significant problems. We can reverse that attitude through sustained campaigning. As has been pointed out, in 2016 North East Lincolnshire, Somerset, Wiltshire, Herts Valley, Cambridgeshire and Peterborough, and Bedfordshire CCGs all cut their fertility services and now offer the bare minimum: one funded IVF cycle. Approximately 10% of CCGs are currently considering disinvestment.
The NICE clinical guidance has been around for more than 10 years. It is important to remember that this is not a static issue: the cost of infertility treatment has fallen dramatically and its effectiveness has increased. The second or third cycle tends to be the one that helps a couple to conceive, so I think NICE was visionary and right to say that three full cycles should be offered to women under 40. It is important to remember that CCGs restrict fertility services not only through the front door by making it clear that they will offer only one cycle, but through the back door by restricting the age at which women can access them. In Oxfordshire, for example, the age limit is 35, not 40.
There is also the issue of how a cycle is defined. In Oxfordshire, one fresh cycle is offered to those under 35, and no frozen transfers are allowed. Other definitions of a cycle allow frozen embryos that have been created from the first cycle to be used, so Oxfordshire does not comply with what I understand to be NICE’s definition of a cycle.
Going back to fertility services being seen as second-class services, Oxfordshire CCG’s response to me when I asked it to comply with the NICE guidelines was, “How are you going to fund it? What other services are we going to have to cut to fund fertility treatment?” It was clearly posited as an either/or, and the undercurrent of the message was, “We are funding the important services. Additional fertility services are a luxury. You are asking us to spend £x million on a luxury.”
To defend Oxfordshire CCG, it uses the NICE cost guidelines when it works out what the additional costs would be. It claims that they would be £2.5 million in year 1, four-and-a-bit million pounds in year 2, £5 million in year 3 and just under £5 million in years 4 and 5. What depresses me about that is the fact that it simply took the off-the-shelf guidance from NICE, which gives the game away: it is simply a desktop exercise by a CCG that is not really interested in addressing the issue. It should be possible for it to investigate with a range of different providers how it can potentially reduce the cost. The cost variation in fertility treatment can range from something like £2,000 to up to £8,000 for a cycle, so it is possible to at least engage with providers to investigate how one can provide a cost-effective service.
I also challenged the CCG on how rigorous it is in stopping services that are out of date and past their usefulness. My understanding—I am sure the Minister will confirm this—is that CCGs should be carrying out an ongoing process of reviewing all the services they are currently funding, because there are probably many services that are out of date or falling into misuse but are still being funded.
I pay tribute to Fertility Fairness, which campaigns assiduously on this issue. It made the point that treatment can cost about £2,000 in the north of England, £6,500 in the south and £3,500 across the UK as a whole. One of its asks, which perhaps the Minister can respond to, is this. CCGs can take refuge by charging the highest cost possible, which acts as a barrier to what we want to achieve. If there were a national tariff, more CCGs might be tempted to come to the table and increase what they are doing to support fertility services.
The Minister is not only a fellow Oxfordshire MP but an absolutely brilliant Health Minister. I know that to a certain extent I am knocking at an open door, because she has spoken very strongly about this issue in public. She said:
“Fertility problems can have a serious and lasting impact on those affected. It is important that the NHS provide access to fertility services for those who need clinical help to start a family. I am very disappointed to learn that access to IVF treatment on the NHS has been reduced in some places and it is unacceptable that some Clinical Commissioning Groups have stopped commissioning it completely. I would strongly encourage all CCGs to implement the NICE Fertility guidelines in full, as many CCGs have successfully done. The Department of Health, NHS England and professional and stakeholder groups are working together to develop benchmark pricing to ensure CCGs can get best value for their local investment.”
That is very welcome news indeed.
The hon. Member for Birmingham, Selly Oak pointed out that there are knock-on costs to not providing fertility treatment in the UK. We know, for example, that many couples understandably go abroad to fund and access fertility services, but different regulations apply abroad. Often, many more embryos are implanted in treatment abroad, which can lead to multiple pregnancies. Multiple pregnancies can lead to greater complications, so paradoxically that can lead to increased costs for the NHS. We would all much prefer people living in the UK to be able to access more familiar services, instead of having to go abroad and take those risks.
I mentioned that all of us speaking in the debate will have real stories to tell. We are speaking not in a vacuum about some impersonal procedure, but about a disease that affects the lives of our constituents significantly. The reason why I supported the hon. Member for Birmingham, Selly Oak in securing the debate, and the reason why I am present, is the letters I receive as a Member of Parliament from my constituents.
One 33-year-old constituent wrote to ask how the situation was fair given that in Wales, Scotland and Northern Ireland, people are entitled to three full cycles of IVF—I understand that the Scottish Government are moving to three full cycles early this year. For four and a half years she and her husband have been trying to conceive. They have been through every test, but all the results have come back as normal, so they have what is called unexplained fertility. They pinned all their hopes on a single funded cycle of IVF, although that was difficult to accept. She points out that infertility is not a choice made by women; they have no control over it. Her first cycle, in August, failed and she went on to a frozen egg cycle, but unfortunately miscarried. Her emotional status is now such that she sees her GP regularly, has been referred to TalkingSpace, an NHS service, and awaits counselling. She was quoted £6,000 for a private cycle—her parents helped with the cost of the treatment—although it transpired that the overall cost was about £8,000. That second cycle failed, too, and the couple will now remortgage their property to fund a third cycle.
Those who think of infertility as a second-order issue should consider that some people will mortgage their financial future to treat the disease, as people might do for other diseases. The idea that infertility is something that one can simply put to one side is absolutely ludicrous. Another constituent wrote about having to go to Barcelona for treatment, which cost about £12,000. A third constituent, at the age of 36, was again refused IVF treatment, and she is now funding her treatment privately.
Infertility is clearly a disease, and one that affects many couples throughout the UK, and some of the devolved Administrations are moving forward on it. I respect the difficult choices that clinical commissioning groups have to make, but the NICE guidance is crystal clear and fair. The guidance sanctions not unlimited cycles but only three, recognising that the first cycle often fails. The technology continues to advance, prices continue to fall and there is little evidence from my CCG or, I suspect, many others of active engagement on the issue, such as research on the ground in real time into what it might cost to procure fertility services, as opposed to simply using off-the-shelf NICE cost guidance to rebut my constituents’ concerns.
The lack of infertility treatment has hidden costs, as the hon. Gentleman said, in mental health and emotional issues and the ongoing costs when people go abroad for treatment that might have an impact back home. A great step forward would be if the Minister were to bring forward a national tariff, or if research were commissioned into some of the ongoing costs of not providing infertility treatment. I encourage the Minister to continue to hold CCGs to account for not complying with NICE guidance.
It is a pleasure to serve under your chairmanship, Mrs Gillan. I congratulate my hon. Friend the Member for Birmingham, Selly Oak (Steve McCabe) and the right hon. Members for Carshalton and Wallington (Tom Brake) and for Wantage (Mr Vaizey) on securing this extremely important and timely debate. As we have heard, difficulty conceiving is a problem that will affect around one in six couples in the UK. I want to highlight the experience of one couple whom I know personally, although many elements of their story will resonate with others who have been affected by fertility problems and experienced difficulties accessing IVF treatment on the NHS.
When that couple made the decision to start a family of their own, there was no doubt in their minds that they would have a child together. Even as the early months of trying yielded no success and as many of the people around them, their friends, family members and colleagues, started to fall pregnant, they remained hopeful and expected that it would simply be a matter of time until they themselves conceived. After more than a year without success, and as the doubts that were absent at the beginning started to emerge, the expected did not happen and a sense of heartache, frustration and anxiety began to replace the hope that had gone before. They visited their GP to ask for help and advice, and so ensued a lengthy process involving tests, hospital referrals, and invasive and non-invasive procedures alike, yet the root cause of the problem remained unexplained.
Just as the couple had all but given up hope of conceiving naturally, they fell pregnant, nearly three years after initially making the decision to start a family together. Here, amid the darkness of their difficult journey towards prospective parenthood, emerged a shining beacon of hope. Yet, as we know, beacons can be so easily and cruelly extinguished, and so it was that only 10 weeks later they endured a devastating and heartbreaking miscarriage. The almost one and a half years that followed the miscarriage were punctuated by a continued inability to conceive, further visits to their GP, more tests and, ultimately, referral back to the hospital. The couple were eventually told in November of last year, nearly five years after starting their journey, that their last, best hope of conceiving was through IVF treatment.
More devastating news was to follow, however, because the couple were told that, despite having a clear clinical need for treatment, they were ineligible to access IVF on the NHS in their area. The reason: their local CCG uses arbitrary access criteria that are not applied in other areas of the country in order to ration access to treatment for financial reasons. A miscarriage in the previous three years is one of the criteria used to deny funding—in essence penalising our couple for experiencing a tragic event over which they had absolutely no control.
The unfairness of the situation is further exacerbated by the knowledge that were the couple to live in a different part of the country—my own area of Coventry, for example—they would be eligible for at least one fully funded cycle of IVF on the NHS. In other areas, they would be eligible for three fully funded cycles. That inequitable postcode lottery adds insult to injury for a couple who, like many others, are already trying to cope with the distressing effects of infertility. The couple are now faced with a situation in which their only opportunity for treatment comes with an enormous financial outlay. Therefore, treatment is reduced to a simple financial decision: those who can afford it have the treatment they need, and those who cannot do not—hardly a just system.
That couple, like many other couples throughout the country who are experiencing fertility problems, deserve fair and equal access to treatment. They deserve an NHS that fulfils its guiding principle of delivering care and treatment free at the point of delivery and according to need. To achieve that, the Government must act to eliminate the regional variations in IVF treatment provision, including the use of arbitrary access criteria, and ultimately seek to ensure that all CCGs routinely commission fertility treatment in line with NICE guidelines. That would mean eligible couples having access to three full cycles of IVF, which would significantly increase the chance of successful conception. I hope that the Minister will make such a commitment.
As no other Members are seeking to catch my eye, I will now move to the winding-up speeches. I call the Opposition spokesman, Mr Justin Madders.
It is a pleasure to serve under your chairmanship, Mrs Gillan. I congratulate my hon. Friend the Member for Birmingham, Selly Oak (Steve McCabe), the right hon. Member for Wantage (Mr Vaizey)—they both made excellent contributions—and the right hon. Member for Carshalton and Wallington (Tom Brake) on securing this extremely important debate. My hon. Friend has been a keen campaigner on this issue, and his expertise and passion were clear when he described the urgent need for change. This is a huge issue that affects many couples up and down the country.
My hon. Friend described the rationing that CCGs are undertaking as crude and based on pseudo-moralistic prejudice. He rightly said that, in other areas of the health service, we would not base decisions on allowing access to treatment on such prejudices. He highlighted well the human aspects of this issue with personal accounts that I do not think any of us could have failed to be moved by, and he rightly highlighted the additional burden on the NHS of having to deal with complications from births resulting from treatments received abroad, where regulatory regimes may be less strict. I do not know whether the Minister is able to examine the cost of that for the health service, but that may be one way to build a financial argument for not rationing treatment. The moral argument has already been put extremely well.
The right hon. Member for Wantage also spoke in a measured and knowledgeable manner. He summed up the issue when he said that signals are being sent that the fertility service is a second-class service. He rightly pointed out that the cost of treatment has come down and its effectiveness has increased. In those circumstances, one would expect availability to improve, but that is clearly not the case. He spoke about the personal experiences of his constituents, one of whom said that infertility is not a choice. That is the perfect riposte to those who argue that IVF treatment is a lifestyle decision.
My hon. Friend the Member for Coventry North East (Colleen Fletcher) spoke about her own friends’ experience. She conveyed clearly how their hope evaporated as time went on, and how after five years that hope was finally dashed on the cruel and inhumane ground that they had suffered a miscarriage in the last three years. We know from other debates how hard it is for a couple to lose a child in that way, so it is surely unconscionable that we allow that to be a factor in denying people access to fertility treatment.
Since being appointed to the Front Bench, I have been involved in several debates about issues that traditionally have not received the attention that they deserve, perhaps because they have been seen as too difficult to discuss or seemed taboo. As my hon. Friend the Member for Birmingham, Selly Oak said, this issue was not debated at all in the previous Parliament, so we clearly do not talk about it enough, despite the fact, as Members have said, that it is the second most common reason for women to visit their GPs. As we have heard, one in seven, or one in six couples are affected by infertility. Whichever of those figures we want to stick with, that means that millions of people face a serious and lasting impact on their lives. Sadly, that results in stress, anxiety, depression and relationship breakdown. In some cases, infertility is the result of another serious condition, the impact of which couples are already having to deal with. I therefore welcome the opportunity to give a voice to people who often struggle silently with this disease and increasingly face the additional frustration of an unfair and unjustifiable postcode lottery.
Before I talk about the rationing and decommissioning of infertility treatment, I, too, want to talk about the human impact to put into context what we are talking about. Like other Members who have spoken, I have been contacted about this issue by a constituent. Her name is Zoey Evans, and she was denied IVF treatment by NHS West Cheshire clinical commissioning group, despite the fact that her infertility was caused by gynaecological treatment, part of which was undertaken without her express consent. The reason the CCG gave for her ineligibility is one that we have heard given by other CCGs—that her partner had a child from a previous relationship. The exceptional circumstances of her case and the cause of her infertility do not appear to have been adequately considered. I know from talking to Zoey how devastating the decision to refuse her the opportunity to become a mother has been for her, and the fact that she finds herself in that position only because of previous treatment on the NHS has made it even more difficult to deal with. Every avenue has been explored. I do not mind saying that I know that Zoey would make a great mum, and it is hugely frustrating to know that, if she had lived in a different area, she might have been given that chance.
Zoey’s situation, like many of the other personal tales we have heard today, demonstrates the point that has been raised already that infertility, as defined by the World Health Organisation, is a disease with an identified treatment—a treatment that is recommended by the National Institute for Health and Care Excellence. We are in a situation where, in some parts of the country, the NHS is allowed to ignore an individual’s healthcare needs as well as the NICE guidelines and effectively add another barrier to treatment by introducing further arbitrary criteria.
In the run-up to this debate, I was contacted by another individual, Richard, who also contacted my hon. Friend the Member for Birmingham, Selly Oak. As we have heard, Richard lives in Dunstable, and as such, he and his partner were entitled to only one cycle of NHS-funded treatment, which sadly was unsuccessful. He emailed me and described what it is like to deal with infertility. My hon. Friend read one quote, but I picked out another, about the human impact, that I thought was equally powerful. Richard said:
“It is very hard to explain to someone who has not experienced infertility the mental health struggle that you go through. If I had to describe our feelings with one statement, I would liken them to the emotion and turmoil that one goes through when a relative dies, the difference being with infertility, the feelings experienced do not slowly ease over time—they intensify.”
He told me of his anger about the fact that, if he lived just one mile from his current address, he would fall into the Luton CCG area, where he would have been entitled to three cycles of treatment rather than the one he received, which might have helped him to become a parent. That illustrates the perverse and cruel nature of the postcode lottery for treatment, which I will now address.
As we know, the NICE clinical guidance on infertility issued in 2004 is extremely clear. It says that
“all eligible couples should have access to three full cycles of IVF where the woman is aged below 40.”
Further guidance was issued in 2013, which recommended that women aged between 40 and 42 should have access to one full cycle. NICE, which was founded in 1999 to end the postcode lottery in prescribing, made those recommendations after deeming such interventions to be a reasonable cost and a clinically effective use of NHS resources. Incredibly, as we have heard, the charity Fertility Fairness found that, of the 209 clinical commissioning groups in England, just four follow the NICE guidance in full, despite CCGs having a legal duty to have regard to NICE guidelines when commissioning treatments. Again, the words of the right hon. Member for Wantage about a second-class service ring true.
When the previous public health Minister, the hon. Member for Battersea (Jane Ellison), was challenged on that in a written question, the response we got was:
“NHS England expects that all those involved in commissioning infertility treatment services to be fully aware of the importance of having regard to the National Institute for Health and Care Excellence fertility guidelines.”
The reality is, as we have heard, that there are enough caveats in that statement to render it meaningless. In another response, she went further and said:
“Blanket restrictions on procedures that do not take account of the individual healthcare needs of patients are unacceptable.”
We all agree with that. However, she stopped short of saying what the Government planned to do about the fact that 98% of CCGs are failing to apply the NICE recommendations in full. We know that at least 45% of them do not offer a full cycle and that more than 80% do not meet the recommendations on the number of cycles. If those restrictions are unacceptable—I think there is general agreement on that—we need to know what Ministers will do to change the situation. What is the point of having NICE recommendations if CCGs, facing huge financial pressures, can disregard them without any penalty?
As my hon. Friend the Member for Birmingham, Selly Oak said, access to treatment is being reduced, and about 10% of CCGs, including my own, West Cheshire, are consulting on that. What can we ask from the Government to stop the further slide away from recommending treatments? Does the Minister accept that something needs to be done? The impression given is that the guidelines can be routinely ignored. Does she accept that the impression can be given of an abrogation of responsibility? Does she accept that that raises real issues about accountability and legitimacy? It is called local decision making, but I do not think people on the receiving end feel that decisions are being made locally in their interests at all.
If the Government do not take a more robust stance when NICE guidance is being ignored by CCGs, they are not only accepting but entrenching the notion of a postcode lottery. We therefore need to look again at whether to strengthen NICE’s role in cases where there is clearly stated treatment that is affordable and effective but we see CCGs failing to implement that advice. I hope that the Minister will reflect on what has been said by me and other Members about how we can move that issue forward.
As we know, infertility treatments are far from the only example of NICE-recommended treatments not being commissioned. Postcode lotteries exist for a whole range of medical interventions such as hernia repair, hip and knee replacements, cataracts and varicose vein surgeries. Further rationings of treatments are being proposed by CCGs across the country as they struggle to cope with finances that simply are not keeping up with demand.
I have mentioned my CCG several times already. I do not wish to be over-critical of it because it is in a difficult position: its core funding allocation for the year is £9 million less than the funding formula says it should be. That gap is projected to close slowly in the next five years, but there will still be millions of pounds of shortfall every year over that period. At a time of increased demand, inevitably, it is being forced into this position, as are many other CCGs. Clearly, financial pressures are driving those decisions not just in my CCG but across the country. That does not chime with the claims we have heard that the health service has been given everything it has asked for.
As my hon. Friend the Member for Birmingham, Selly Oak and the right hon. Member for Wantage said, the postcode lottery is exacerbated by the huge variance in the amounts that CCGs pay for a single cycle of IVF, from as low as just over £2,000 to possibly three times as much in other parts of the country. In response to a written question on 21 April 2016, the previous public health Minister said that
“the Department and NHS England are considering options for addressing variation in the prices that CCGs are currently paying for in vitro fertilisation treatment.”
A report by an expert group on commissioning NHS infertility provision identified that
“a lack of knowledge and expertise in commissioning fertility services was a barrier to compliance with NICE guidelines”.
How close are we to a national benchmark on price? What support can be put in place to assist CCGs when they are commissioning fertility services?
I bring my remarks to a close by reminding us of the founding principles of the national health service: good healthcare, available to all and free at the point of use. Those founding principles came some 30 years before the first IVF birth, but, whatever the advances in medical science, they should apply to any treatments where a medical case is made for their use, not just to people living in certain parts of the country.
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.
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?
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.
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?
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.
I thank the various Members who have taken part in this debate: the right hon. Member for Wantage (Mr Vaizey), my hon. Friends the Members for Coventry North East (Colleen Fletcher) and for Ellesmere Port and Neston (Justin Madders) and the hon. Member for South West Bedfordshire (Andrew Selous), who has now left. It is never easy on a Thursday afternoon, but I really felt we had to have some focus on this issue in this place today.
I am extremely grateful to the Minister for the tone she adopted in her response. One reason why I asked her to instigate an investigation into what is happening is that I understand, from a parliamentary question I submitted, that the Government do not, as a matter of routine, centrally collect information on the provision of infertility services. While I acknowledge her point about provision being locally determined, the extent of the disparity has been a revelation to me. It is difficult to believe we are talking about a national health service when we see that level of disparity. I gently say to her that there would still be some merit in a further investigation into the extent of the variation in England at present.
I am extremely pleased to hear that the Minister plans to write to NHS England. I interpret that as meaning she will put pressure on NHS England to put pressure on the CCGs that are not complying with the NICE guidelines. I will certainly take the opportunity to write to NICE about the experience of same-sex couples, as she suggested, although the key here is obviously that the NICE guidelines have to be followed. That is the central problem.
I was extremely pleased to hear that the Minister is taking steps on benchmark pricing, which may well lead to the construction of a national tariff. All I will say on that is: the sooner, the better. If she were able at some stage to offer us a realistic timescale for that, it would be some comfort to the very many people who have contacted all of us to explain the pain and anguish they have suffered as a result of this condition. I am grateful to Members for their contributions and to the Minister for a thoughtful response.
This has been a very valuable and important debate.
Question put and agreed to.
That this House has considered decommissioning of in vitro fertilisation and other NHS fertility services.