Tuesday, August 07, 2012

Will a Baby Boom Bust the NHS?

The following article was published in the Health Service Journal on 26th July 2012, which I co-wrote.  It considers how the NHS can financially cope with the increased demand expected in NHS IVF, especially following the new NICE guidelines:

The provision of NHS fertility treatment is set to become even more contentious with the 2012 update to the National Institute of Health and Clinical Excellence Guidelines currently under consultation.

A draft release of the new guidelines in May suggested that eligibility will be widened to encompass same sex couples, single women and clarify the definition of “full cycle”, which has previously been open to interpretation. In addition, the upper age limit for treatment is likely to rise to 42.

The original NICE guidelines on assessment and treatment of fertility problems in 2004 standardised the eligibility criteria for NHS-funded treatment nationally and recommended three cycles of IVF per patient, who were:

women in a stable, heterosexual relationship who had been actively trying to conceive for three years;
aged 25-37 at the start of treatment;
and had a BMI of 23-29.

NICE guidelines are based on clinical evidence underlined by economic efficiency: three cycles allows the best chance of success (clinical effectiveness is unclear for subsequent treatment) and advocates argue this also offers the most attractive spend-to- success ratio.

As these guidelines are not mandatory, the English NHS developed significant variation of provision. Primary care trusts had been free to tailor the criteria and number of cycles offered to fit policy and resources, and as recent cuts have started to bite many commissioners have reduced the funding available to fertility, some suspending or cutting it completely.

When clinical commissioning groups take over from PCTs next year it will be up to them to decide how they allocate resources. But with 52 PCTs being dismantled to be replaced by over 200 CCGs, many believe that equality of access will decline further.

Fertility as a subject is highly emotive and the arguments for and against NHS-funded treatment provision are well rehearsed. Infertility is estimated to affect one in six couples in the UK, and for women is the second most common reason after pregnancy itself for seeing their GP. On an ideological level, if a citizen works hard and pays their taxes, why should they not receive the treatment they require?

On the flip side, although infertility is recognised by the World Health Organisation as a medical condition, it is not viewed as a matter of medical need by many who fund and commission treatment. It is neither life-threatening nor seriously injurious to physical well-being - even the staunchest supporters of NHS treatment admit gracefully that it is hardly on a par with cancer drugs or life-saving surgery.

This is reflected in the attitudes of many employers and clinicians: more often than not, women undergoing treatment are not allowed paid time away from work for appointments and a recent Infertility Network survey suggests that, for over half of patients surveyed, initial GP contact for suspected infertility is either ill-informed or unsympathetic.

However, in the 2011 survey of fertility services commissioners, most responded that the primary reason their PCT did not offer three full cycles was cost. So, should this inequality be addressed or accepted as an unavoidable result of today’s need to balance the books?

An even bigger issue on the table goes to the heart of what the NHS exists to do. Society and healthcare have been irrevocably transformed since the 1940s and the NHS must also evolve and offer treatments well beyond the scope of what it was conceived to deliver. While parenthood may not be an absolute right, where the technology exists, the pressure to prescribe follows.

However, away from the scaremongering headlines, most clinical and political leaders would agree that the gap between idealism and pragmatism must be addressed to prevent future ruin. If NICE does review the age range guidelines as expected, in addition to offering treatment to single women and same sex female couples, the demand for NHS treatment may sky rocket.

At present, one of the key drivers into the private market is age as women ineligible according to current guidelines have no option of NHS treatment. After changes to the rules on donorship and registration of births in 2009, same-sex women seeking treatment doubled on 2007.

Future challenges

So what is the answer? How can NHS managers tame both monsters: patient satisfaction and budgetary necessity?

Fertility treatment is an easy target for financial cuts. The political health reforms complicate the situation further: how will IVF work in the world of increased patient choice, with outcomes and equality of access the mantra of the day?

Patients may exercise their right to choose. For example, if your GP tells you that your CCG does not procure IVF services, you could simply re-register with another GP, who is in an area that offers IVF treatment. Hence, passing the financial buck to another CCG. The consequence may be that commissioners find it increasingly difficult to balance supply and demand.

PCTs have so far been used to dealing with population analytics, but in this brave new world of patient choice and online access, the numerical analytics of what constitutes your local population base may look very different.

NICE currently has its hands full preparing revisions to guidelines, with the stress on quality and outcomes - success of treatment is measured against equality of access and may make the concept of a postcode lottery untenable, even unlawful.

So do the new fertility guidelines present emerging CCGs with just one more additional dilemma while they struggle with major reforms? How can the NHS be expected to increase fertility provision, while the government expects it to save £20bn a year?

Maybe the NHS must take a leaf out of the book of competitive, cost-conscious private providers by working smarter, not just harder. These are some of our suggestions:

Contracts and pricing Currently PCTs tend to spot-purchase IVF treatment, which often leaves the balance of power in the hands of the provider, who demands a high price for low-volume referrals. In some regions, PCTs have grouped together and asked the SHAs to purchase IVF treatment for an entire region - this has increased referral volume, but the SHAs have again frequently used spot purchasing.

In the future it may be that block/bulk buying is one way for the NHS to leverage its formidable purchasing power. To do this, CCGs would have to work together; as yet there is little evidence of this happening for IVF provision. If all CCGs decide to commission independently, the bulk buying power would be weakened. Also as there is no national tariff or suggested price guidelines regarding IVF, the private providers offering services back to the NHS are not incentivised to make their rates competitive or offer an NHS bulk-buy discounted rate.

In the future, a forward-thinking IVF provider may consider an NHS discounted rate for a large enough block contract although this would require greater private market consolidation to provide a player large enough.

Training costs With the public and private sector on an equal footing in the marketplace, commissioned contract prices should also take into account the cost to the NHS of training such highly specialised staff. Currently, the NHS bears the lion’s share of the training costs and training time, while private companies benefit from consultant-led services as clinicians develop in their careers and move into the private sector. In the future, commissioners may want to consider asking private companies to contribute to both training and research and development.

National Commissioning Board IVF services are currently not part of what will be commissioned at the National Commissioning Board level, but are to be commissioned by CCGs. This not only means that bulk purchasing benefits may be dispersed but that each CCG may independently consider evidence from NICE and commission with different interpretations. It may well make more sense for the board to consider the NICE guidelines and commission to end the postcode lottery of IVF interpretation.

In these austere times there is no bottomless pit of money and CCGs will be looking to make savings wherever possible. A single point of interpretation is more likely to result in women receiving the treatment they seek.

We need to start having these discussions now. The expansion of IVF treatment guidelines may well turn into a major political challenge, with a perfect storm on the horizon.

IVF puts the spotlight on the ethical question of who decides what services the NHS will deliver. After all, it is not mandatory for PCTs to deliver on NICE guidelines and there is no suggestion that CCGs will be in any different position. Also, the suggested expansion of IVF provision comes at a time of wholesale commissioning upheaval so these as yet untested CCGs will be asked to deliver more provision with reduced costs. It’s a big ask.

IVF has always been an emotive topic and with increased patient choice, the debate may be dominated by who shouts the loudest. These complex and challenging issues both financially and ethically are soon to be faced by either 212 CCGs or one NCB. Success may well be dependent on engaging with the already significant expertise held by fertility experts and patient groups to provide a benchmark for efficient commissioning. Failure would represent a significant missed opportunity.

Sarah Downes is a management consultant at Candesic and Dr Michelle Tempest is a liaison psychiatrist for the NHS and management consultant for Candesic.