Examination of Witnesses (Questions 40-59)
CAROLINE FLINT
MP, MR HUGH
WHITTALL AND
MR TED
WEBB
12 JULY 2006
Q40 Dr Turner: Caroline, does it
not worry you as a health minister that there is such a general
problem with NICE guidance not being taken up? NICE have recommended
three cycles, with some PCTs it has been very difficult for a
woman to get one, let alone three, and the reason for this is
very basic, that those PCTs are worried about the cost. This is
affecting a whole range of NICE guidelines, very often in areas
which are particularly pertinent to women. We need to find some
way of dealing with this, do we not, otherwise NICE is going to
be increasingly superfluous.
Caroline Flint: First of all,
I think the NICE guideline was very helpful in terms of the focus
on infertility and raising awareness of the debate. NICE is not
a guideline that necessarily people expected the NHS and the PCTs
to provide straight away, by any means, but actually something
they could aim for. I think part of what we are trying to do,
which I was explaining to Brian, is first of all look at how we
could, working with the PCTs but also other groups as well, try
to improve understanding and knowledge of the best way to commission
fertility services with the most successful outcomes, and I think
this comes to some discussion about the point you made about European
clinics and some of the issues around different success rates,
which, as I say, is not always clear—often some of the clinics
with the worse success rates may be taking the more difficult
patients and you have to be mindful of that. It is also why we
have provided some resources for Infertility Network UK to actually
do some work for us, which they will be reporting back to us,
and on working with PCTs to again continue the raising of the
importance in this area, and both practical ways, hopefully, in
which PCTs might improve the way they commission and the sort
of services they provide, and how they actually tackle infertility
issues locally, and part of that, I have to say for the PCT, is
trying to prevent the infertility problems that may occur down
the road because that, more than anything, could have an impact
on reducing the numbers who will have to call on IVF in the future.
Chairman: Minister, could I ask you to
try and make your answers a little shorter so that we can try
and get through the programme?
Q41 Dr Harris: Can I welcome what
you have said about success rates and the dangers of using them
as a blunt instrument because of the danger of patient selection?
Are you aware that when NICE said that there should be two cycles
and the government said, "You must do a minimum of one"
that some PCTs who were given two or three just reduced to one
to comply with what you said. Is that a gain for patients in those
areas? Clearly it is not. Do you regret it?
Caroline Flint: It was not meant
to be a situation where one view was set against the other.
Q42 Dr Harris: But that has happened.
Caroline Flint: I think that is
important but I think the fact of the matter is that what the
government was saying at the time was that given that the NICE
guideline was three was not something that they expected to happen
in the short span of time. At the time the Secretary of State
was trying to indicate that there should be every effort to make
at least one cycle available. That was not meant to be seen to
contradict NICE but, again, as I have said, in the last year we
have been trying to look at how we can improve and to get evidence
of where services have been provided and where they are not provided
so that we condition tackle some of the issues.
Q43 Dr Harris: The guidance and indeed
the government's guidance says that these services should be given
to appropriate patients. Are you aware that every PCT has a its
own eligibility criteria about whether women are married, whether
there is already one child living there, they all have different
age limits. NICE and indeed the government were supposed to end
those postcode variations in the provision but it just depends
on how old you are, where you live, who you are living with and
what your marital status is. Is that satisfactory?
Caroline Flint: Again, some of
these decisions do have to be made by PCTs in line with how they
develop local services and that does present, I know, some difficult
issues for both the families involved and also some of the organisations
who are concerned about improving services. But we do look at
these areas and we have meetings with different organisations
about some of these problems and issues and we are always looking
at it and thinking through, "What shall we do next?"
But ultimately PCTs, as in a whole range of other health areas,
have to decide how it is going to spend its budget and therefore
will set parameters in some areas for that expending, and that
is something that needs to be taken up locally and that is why
Infertility Network UK has been asked to work with local people
to raise these issues with their own PCT.
Q44 Dr Harris: Dr Patricia Rashbrook
wanted to have treatment to bring a wanted child into a loving
family and she, as an intelligent woman, knew the chances of success,
knew how much it was going to cost and she knew the success chances
were limited but was prepared to do that with informed consent
as an adult person. Do you think it is unfortunate that she could
not do that in this country and that women like her are not able
to bring healthy wanted children into a loving family in that
way?
Caroline Flint: There is no legal
age limit on the age at which women can be treated but there is
a general view amongst UK clinicians that they do draw a line
at or around the menopause and that is something that has come
from clinicians themselves. I think that is a matter for clinicians
and patients to take these matters into account of providing treatment
in these areas.
Dr Harris: That is very helpful because
that was the thrust of the Select Committee's report, with informed
consent the GMC and Healthcare Commission are already acting in
this area and it should not be for government, regulators or even
the media to say what treatment individual people should get within
that framework of existing regulation. It is helpful you have
clarified that.
Chairman: Thank you. Brian.
Q45 Dr Iddon: When we published our
report last year, Caroline, the Press focused on one thing above
any other and that was on sex selection, so I think we had better
ask you a few questions about that this morning. What is the government's
current thinking on allowing or disallowing sex selection for
non-medical reasons?
Caroline Flint: It has been established
government policy that sex selection should only be allowed for
serious medical reasons. There is no legal ban as such on non-medical
sex selection. The consultation I think certainly backed up our
view in terms of serious medical conditions and I have to say
that I do not think that we are of a view that that should be
changing, so we are minded to pursue a clear and explicit ban
in the law which covers all assisted reproduction treatments in
relation to sex selection, where it is not for serious medical
conditions.
Q46 Dr Iddon: So are you going to
regulate sex selection by sperm sorting?
Caroline Flint: Again, and I think
I said this last week in the debate, whilst we do feel we should
have a specific ban I think there are some practical considerations
that we have to work through that are linked to the technologies
and are linked to issues around the private arrangements, and
also in terms of issues around the Internet too. I just wanted
to flag up today that this is what we are minded to do but we
are working through some of the practical issues about how that
will be enforced and how that will be developed.
Q47 Dr Iddon: If it were proven—and
I think it possibly could—that sex selection does not cause
harm, what are the reasons for disallowing people to choose clinical
treatment for sex selection, particularly for family balancing
reasons?
Caroline Flint: I do believe that
there is an understanding around using sex selection for where
there are serious medical conditions and I think that that is
something that has been backed up by the responses to our consultation,
but I think on family balancing the problem is that it can be
a slippery slope in terms of people deciding that one gender is
more important than the other, and the problem in this area is
that there will be many individual cases that people might bring
forward but the problem is in trying to have a law and a system
that can deal with where we feel that that would be an inappropriate
use of sex selection. So I think we have to be mindful about opening
a door potentially to what I would consider and I think what most
people would consider is not an appropriate use of sex selection
in terms of gender priorities.
Q48 Dr Iddon: You used the term "slippery
slope" there. Is it your main concern that if we allow sex
selection, even for family balancing reasons, and assuming it
was entirely safe, that people would then start to demand babies
with other desirable characteristics like blue eyes—the
blue eye syndrome.
Caroline Flint: We are certainly
not into that sort of designing. I think the issue around sex
selection is an issue for us nationally in terms of the appropriateness
of prioritising one gender over another, but I also think that
there is a wider impact in terms of allowing this in law, which
goes beyond our own country, and the message it sends out around
the worth of boys and girls.
Q49 Dr Iddon: Can I also put it to
you, Minister, that it is not unknown for people who cannot get
a baby of the right gender here in Britain that they go abroad?
So what is the government's view on reproductive tourism?
Caroline Flint: Again, we can
only do so much in our law and we have seen in other aspects of
IVF that people have gone overseas for certain treatments, so
we can only do so much in what we do. But I think one of the things
we do do, by being clear about our own law, is to send out a message
about what we believe is right at any given time and what is appropriate.
We cannot manage the law around the world, but certainly in terms
of the organisations we are involved with around the world in
this area and also in other areas of health we have our own view,
which we bring to discussion in those forums. But we cannot control
what other countries do and we cannot necessarily control what
an individual wishes to do by going overseas, and that is the
same for other matters beyond this area, whether it is plastic
surgery or anything else—we can only do so much. But I think
what we need to be sure about is alerting people to the dangers
of going overseas for medical treatment, that they may not have
the safety and the quality as they do at home.
Q50 Adam Afriyie: So you are saying
that if someone has enough money to travel abroad to have sex
selection, then you are satisfied with that and there is nothing
you are looking to do to change the situation?
Caroline Flint: No, the starting
point of this discussion is whether we would believe that sex
selection should be allowed for non-medical reasons, and purely
in terms of family balancing it could be in one case that someone
could make a case for that; it could be for other less worthy
motives, maybe, if that is the right word.
Q51 Adam Afriyie: But you are saying
that you are not going to prosecute somebody who goes abroad to
make a sex selection choice?
Caroline Flint: I do not believe
that is something that we would have the remit to do. If somebody
goes to another country in which for that country it is legal
to take part in that—and I take your point about money,
but that is the same for a lot of things, I am afraid to say—the
question is whether or not we believe that sex selection for non-medical
reasons is something that we should allow to happen, and our view
is that we should not. There are some practicalities that are
not easy in this area that we are going to have work through and
think through about how we are going to deal with those. But certainly
we cannot control everything beyond the bounds of our own borders.
Q52 Dr Iddon: But who will take the
final decision, Caroline? Will it be the regulator or will it
be parliament, and which factors will we take into consideration
the most? Are you basing what you said just now mainly on public
opinion or is it the practicality of regulation or is it the potential
for harm?
Caroline Flint: As I say, public
opinion in that includes a number of different organisations who
have also made known their views on this, from a range of standpoints,
and what we have seen is that there is a view that sex selection
for medical reasons is something that we should be looking at,
but not for non-medical reasons, and we will be looking to see
how we can make that clear in the law so that there is a very
strong steer to the regulator about how that could be applied.
But there are some practicalities, as you have said, some of which
have been raised this morning, which we have to work through as
to how we deal with that.
Q53 Dr Iddon: So Parliament will
decide, that is what you are saying?
Caroline Flint: We will have some
legislation that Parliament will decide upon.
Q54 Chairman: Can I move on to PGD,
and you mentioned earlier that this might be an area in which
you would want to see Parliament take a more specific role in
terms of determining it. At the moment, are you content for the
HFEA and its successor, RATE, to make decisions on conditions
for which screening can be undertaken using the PGD?
Caroline Flint: As you know, there
are no criteria in the law at the moment to determine when screening
selection—
Q55 Chairman: No, are you content
for them to do it?
Caroline Flint: I think what we
have felt is that we are giving some very serious consideration
to criteria which should be available in the legislation in the
future, and that is something that I know this Committee was in
favour of. It has come across strongly in the responses to the
consultation and I have to say was also recommended by the HFEA.
So that is something that we are giving some serious consideration
as to what that criteria might be; and as a general rule I think
that even if we have that criteria we will still need to see a
role for the regulator in terms of making sure that that criteria
is used in practice.
Q56 Chairman: I think if you talk
about slippery slopes, which you mentioned earlier, when, in fact,
the regulator came in, in terms of looking at PGD, there were
a number of known conditions for which screening would take place.
We have now got the situation over the river at St Thomas' and
Guys where hundreds of conditions can be screened using PGD techniques,
for instance about the potential to get a cancer later on in life.
Do you really think that is the job of the regulator to be making
those decisions and not Parliament itself? What do you think?
Caroline Flint: I think what is
important is that the law is clear in terms of the criteria and
in terms of how this can be applied. That may involve some general
principles which have to be applied, it will have to allow some
flexibility for the regulator to apply the law.
Q57 Chairman: Who makes those principles?
Who decides?
Caroline Flint: What we are suggesting
is what we are looking at, and giving some consideration, to is
how we can have those general principles as part of the legislation.
At the moment there is nothing there and I can understand why
there is disquiet at that because there are no general principles
there per se. What we are working through is thinking about how,
through legislation, those general principles, that criteria,
can be part of the legislation but which does allow some role
for the regulator in being able to respond to some new developments
as they occur. Obviously, as and when our proposals come forward,
I am sure we will have debate about whether the general principles
are sufficiently robust enough to cover, as much as possible,
the ability to both give some clear direction but also to be able
to respond to some developments as they emerge.
Q58 Chairman: Why should the regulator
be involved at all? If you find that Parliament sets down the
clear grant which PGD can be offered, why is it not then just
up to clinicians and patients themselves? What has the regulator
got to do with it?
Caroline Flint: The regulator
acts on behalf of government to make sure that practices are carried
out properly and that criterion is used properly, and that is
part of their job. I think that is something in this particular
area which the general public would want but, I have to say, some
of the organisations, like the BMA and others, also still see
a role for the regulator in playing a role in these areas. It
is not like the regulator does not have ongoing discussions with
clinicians about these issues, with scientists about developments
in this area. They are informed through their advisory panels
in relation to all these areas, there is an ongoing discussion
as there would be. The idea that the regulator should have some
role in terms of supporting or informing developments by their
role as the regulator of the law, because that is their job, is
important in these areas. It is not something that I have particularly
found some of the professional bodies to have a problem with.
Q59 Chairman: It does not happen
in any other area of medicine, does it?
Caroline Flint: Again, we talked
earlier about the importance of this particular area of medicine
compared with others in relation to decisions about life and the
creation of life. That is why it has that special place in terms
of Parliament's considerations and also in terms of the public's
consideration and ultimately about creating a framework and legislation
which has confidence and can be useful, both in terms of regulating
present practices and procedures but also being able to respond
to changes as they occur.
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