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31 Jan 2007 : Column 118WHcontinued
all free on the NHS. A second statement said that, when that investigation has achieved a conclusion, if it is considered appropriate, in vitro fertilisation should be the next step and a full cycle of IVF should be made
available to couples. That was a staggeringly valuable and important moment for ordinary people who are desperate for that one thing.
However, PCTs do not or cannot support both statements. Either it is a financial matter, or it is a policy decision that they do not support. When we surveyed PCTs many of them simply did not respond, and we are left to think that that was because infertility is a low priority for them. We wanted to know where their struggles or concern arose, but they did not respond. Also, in discussing this question, PCTs ask what a full cycle meansone embryo implantation or three? There is worrying ambivalence, and not because those involved take the view that one course of action is cheaper and they will choose it; they believe that it is appropriate, and they put the treatment in place. Thus PCTs are not adopting the procedure that the Secretary of State has supported.
PCTs also tell women that they must be over 30or sometimes over 34 or 36. I do not need to repeat what the hon. Member for Romsey said. The ability to conceive is growing less and less at that age, but a 22-year-old who has undergone all the treatments and diagnosis will be told, Sorry, you have to wait. That is not a sensible approach, and I am appalled that, 30 years on from my infertility treatment, I face the same hideous black, blank walls that I faced all those years ago. That is unacceptable. I ask the Minister today to impose compulsiona regulationon PCTs to do one easy thing: there should be open and clear evidence of the priorities that they define. We should know their stated priority for their locality. It should be open and unequivocal, so that we can see where their priorities lie. If there is a problem financially, let us hear about it.
In the north, we have the very valuable Centre at Life in Newcastle, with Professor Alison Murdoch. It is an incredible research-based institution that does state-of-the art development work. People in Newcastle and the surrounding area are getting the best of treatments. That is not the case for people in Stockton today.
I am very keen to acknowledge what is being done, but also to point out that what is being done is often ambivalent and unclear. Sometimes decisions are not being implemented. We do not have a national health service that treats infertile couples equally. Some people have that treatment; others receive a minimal service, and some pay through the nose for a service. It is not free; it is certainly not fair, and it is not equal. I ask the Minister to acknowledge that, and to insist that the PCTs should publicise in an open and transparent way which treatments they regard as appropriate when they engage in commissioning and use their funding. I ask her to state clearlyto make a formal regulatory statementthat all PCTs should acknowledge three embryo implantations to be the formal definition of one cycle, so that the ambivalence is removed.
I also ask the Minister to consider the Human Fertilisation and Embryology Authority with great caution. I have great concerns about much that comes out of it, and the White Paper consultation should involve taking note of what the medics in the profession are saying. I hope that that is what will happen.
I argue with passion, and I hope that I have not gone too much over my time. I have been involved in this issue for 30-odd years. I was so pleased when the
Labour Government decided that funding should be made more available and that IVF cycles should be clearly defined as appropriate for infertile couples, but I am quite distressed to have to tell the Minister that we need a clearer, more careful examination of the treatments that are offered to our constituents, and we need very firm handling for PCTs when they are defining treatments as appropriate or inappropriate for those people.
Norman Lamb (North Norfolk) (LD): It is a pleasure to follow the hon. Member for Stockton, South (Ms Taylor), who made a passionate speech based on her personal experience. She obviously knows the subject well, having followed it through the years. I strongly support what she said about the importance of openness in the setting of priorities by PCTs. At the moment, there is not the transparency that the public need.
I congratulate my hon. Friend the Member for Romsey (Sandra Gidley) on securing the debate. I found the debate fascinating andas you said earlier, Mr. Cookhon. Members are clearly well informed. It has been a pleasure to listen to the contributions of all the hon. Members who have spoken. My hon. Friend talked about the great public support for NHS treatment. We might not automatically assume that such support exists, but the evidence so far shows it does. She also referred to two surveysher own and one by NICE. I am sure that they are both equally authoritative; but both found slow progress in implementing the NICE guidelines. That should be of concern to us all.
My hon. Friend mentioned the possible boost to the economyand referred to academic support in that contextand discussed whether infertility treatment should be considered as part of a population strategy. I was fascinated by the point that she made about combining single embryo transfer with the introduction of three cycles to give the maximum chance of success.
It was fascinating to hear about the experiences of my hon. Friendperhaps I may refer to the hon. Member for Norwich, North (Dr. Gibson) in that wayand particularly about the conference that he attended just before Christmas. It seems that we can secure a better success rate and greater safety for women at lower cost to the NHSa win-win-win situationif we can follow the guidance that emerged at the conference. It was interesting to hear of the international comparisons, and the overseas evidence that it is possible to achieve a higher success rate with lower hormone use.
The side effects of overdosing on hormone treatment are a matter of real concern, and I ask the Minister if she can respond to the evidence we have heard about that today. Will she explain what the Department is doing to follow best practice from overseas and ensure that we maximise the availability of NHS treatment by reducing the cost as much as possible in that way? I think the hon. Gentleman described that much safer approach as semi-natural, and it is an attractive proposition.
I come to the subject with no great background knowledge, and I was amazed when I realised quite what proportion of couples need helpone in six or
one or seven, or possibly one in four, as the hon. Member for Stockton, South mentioned. I am acutely aware of the pain and distress that infertility causesthe hon. Lady referred to the despair that is felt. She described infertility as a disease, which is how it ought be considered so that we overcome the hurdle of it seeming like an optional extra for the NHS. That was an interesting way to describe it.
On international comparisons, I was interested to note that in the UK there are about 580 cycles of fertility treatment each year per million of the population, whereas in most other northern European countries there are about 1,050 per milliongetting on for double the rate. In Denmark, 3.7 per cent. of babies are born as a result of IVF treatment, whereas in the UK the figure is just 1 per cent. I shall return to the economic case for at least considering a debate on extending the availability of IVF treatment.
I appreciate that the 2004 NICE guidelines were not mandatory, but were set out as an objective. However, they gave the clear statement that there should be three cycles of stimulated IVF treatment for women between 23 and 39. We all support NICE and see it as a wonderfully independent, objective basis for determining what the NHS should be doing. It seems contradictory, then, effectively to ignore its judgment in practice. It is not ultimately being followed. The Government supported the guidelines and gave a positive response to them, mentioning a phased introduction of the target of three cycles.
My hon. Friend the Member for Cheltenham (Martin Horwood) mentioned the evidence from around the country on the impact of deficits. Before Christmas, in its report on deficits, the Health Committee said that soft targets suffer most when trusts are deep in deficit. Answering a question recently, the Minister said that Gloucestershire, North Lincolnshire and Northamptonshire PCTs had all suspended fertility treatment. I ask her for an update on that: are more PCTs going down that route? I know that many have deep financial difficulties because of historic debt and that it is tempting for PCTs to do that. However, it is not sensible or right. Is the Minister sending PCTs any advice or guidance on the matter?
There has not been central guidance from the Department of Health to strategic health authorities or PCTs on implementing the NICE guidelines. Is such guidance expected and, if so, when? My hon. Friend the Member for Romsey mentioned that there has not yet been guidance on how to prioritise treatment for patients of varying social criteria. We heard earlier that the then Secretary of State introduced a social criterion immediately after the introduction of the guidelines by saying, effectively, that fertility treatment should not be available to families that already had a child, even one born to only one of the parents. Is that where it will end or will there be more objective criteria for determining the social factors to be taken into account?
I wish to mention the value and importance of information for couples. It is critical for couples to be given good-quality information on the optimal age range and matters such as the impact of smoking, alcohol, caffeine consumption and body weight. People
ought to be informed about such things so that they can make better judgments and improve their prospects of giving birth.
I turn briefly to economic issues. We are experiencing low birth rates across the developed world. I was fascinated by what the hon. Member for Norwich, North said about the reasons for the decline in birth rates: the impact of sexually transmitted diseases, a reduction in sperm count for whatever reason
Dr. Gibson: Too much time listening to The Archers.
Norman Lamb: That might be an affliction that the hon. Gentleman suffers from.
Birth rates are now frequently below replacement rates, which poses big questions for Governments in the developed world. At the same time, we have an ageing population. The ratio between the working and retired populations is changing to a disturbing degree. I am not sure whether it has been as a direct result of that, but part of the solution has been immigration. People of working age have come to this country, which has helped to increase the productive work force and to support the retired, ageing population through taxation. However, given current population trends, that is not enough. Any cuts to welfare entitlements will be heavily resisted and the pressure on Governments will be intense, considering the extent of the ageing population and the reduction in the proportion of people in work.
Another consideration is whether one can do anything to raise fertility rates. There should be a debate about whether extending the availability of IVF treatment should be considered in the mix of policy approaches. This is a growing problem for the western developed world. What are the Government doing to research that big policy area and what issues are they considering?
This has been an absolutely fascinating debate and I have learned a lot. There have been impassioned pleas for more to be done to ensure that people get access to treatment, and the chink of light at the end of the tunnel is that it might be possible to do so without inordinate cost to the NHS. That is the potential prize, and I will be interested to hear from the Minister what the Government are doing to ensure that we secure it. Apart from anything else, we should do everything that we can to resolve the personal pain and anguish that couples go through.
Mr. Andrew Lansley (South Cambridgeshire) (Con): I share with others the sense that this has been a good and timely debate. I, too, congratulate the hon. Member for Romsey (Sandra Gidley) on initiating it. We are about two years on from the last time this subject was debated here in Westminster Hall and approaching three years from the point at which the NICE guidelines were promulgated. It is important for us to take stockI was going to say of the progress, but to some extent it is the lack of progress, that has been made since then.
It has been said a number of times that the Government welcomed the guidelines but, as I said at the time, they welcomed NICEs production of them
and immediately, as it were, removed two of the three stumps. There is no point in asking NICE to produce guidelines and then for the Governmentthe then Secretary of State himselfto strip away one of their central conclusions. The guidelines stand together.
It has not been mentioned that the reason why three cycles of IVF are recommended is that that maximises the chances of success. Beyond three, the chances of success are subject to a law of diminishing returns. Going down to just one cycle means that there is probably half the chance of success of three cycles, yet the NHS is likely to have invested considerable effort in diagnosis and early investigations, much of which is likely to be wasted. There is a central point there about the NHS and NICE examining what is clinically and cost-effective.
Martin Horwood: The hon. Gentleman is absolutely right when he cites the financial investment and investigation process that precedes that one cycle. It is much more cost-effective to provide three. However, there is also the familys emotional investment, which again builds up to just one cycle. It is much more effective for them, too, if there are three cycles.
Mr. Lansley: That is right. Indeed, the hon. Member for Stockton, South (Ms Taylor) reminded us of the sense of distressof a disease, as it werethat can be occasioned for couples who are infertile. They have a profound sense that the NHS is not there for them. As vice-chair of the all-party infertility group, I am glad that the hon. Lady was present to make those points. We have all discussed surveys, and the group undertook its own survey of primary care trusts in early 2005, producing what I think were authoritative results.
Two years ago, the then Public Health Minister said in this Chamber:
Where existing provision is greater than one cyclethat is, two, as in the Rother Valley constituencywe expect provision to continue at least at that level.[Official Report, Westminster Hall, 26 January 2005; Vol. 430, c. 109WH.]
That is, from April 2005 onwards. One distressing result not mentioned is that, of the results that the all-party group received, 20 of the PCTs that funded more than one cycle intended to reduce their provision to one cycle from April 2005. Unless I am very much mistaken, a number of PCTs are still doing so. If they are not, I hope that the Minister will tell us. However, the concern continues.
Dr. Gibson: Does the hon. Gentleman agree that all that argument might be irrelevant if it were proven that three cycles were no better than one cycle, minus the hormone stimulation received three times, and the fact that the individuals recovery rate was better and the embryos were in better nick than they would have been after three loads of hormone treatment? Perhaps the evidence shows that once is enough.
I share the sense that the NHS should do what is most clinically and cost-effective. It is NICEs job to do that. People say that the Department of Health should undertake research, but that is NICEs job. It routinely revisits its guidelines to take account of the cost-effectiveness of single-embryo transfersthe cost-effectiveness evidence that the hon.
Gentleman puts forward on minimally stimulated ovarian cycles. Bourn Hall clinic, where Robert Edwards and Patrick Steptoe began their work on IVF, is in my constituency, and I have seen its success rate with blast-assist transfers. There is a lot of potential, and it must be incorporated in the NICE guidelines.
To return to my central point, what is the point of asking NICE to revisit the guidelines and publish new ones if the Government still say that NICE guidelines will be superseded by statements from the Secretary of State? That is what they have done. Most PCTs have no intention of implementing the NICE guidelines in full and they have no timetable for doing so.
The hon. Member for Cheltenham (Martin Horwood) mentioned Gloucestershire, where IVF has been effectively suspended. As he may recall, the then Cambridge City and South Cambridgeshire PCT did so in the latter part of last year, too. It reinstituted IVF availability, but it is currently rationed. There might be 300 to 400 couples who require IVF each year, but the number has been restricted to 200. People simply go on to a waiting list, and more people are joining it than there are IVF cycles available.
The hon. Member for North Norfolk (Norman Lamb) asked where IVF is not available, and the Minister may know. I know that when I was in Yorkshire two weeks ago, GPs handed me a document dated 22 December from the North Yorkshire and York PCT, which said, among other things:
With immediate effect, the PCT proposes to suspend the routine commissioning of a range of surgical and other treatments for a range of common non life threatening conditions.
I did not know that the NHS had arrived at the point where it treated only life threatening conditions, but it seems to be true. IVF is listed under the heading Suspension of Services, so it will not be available in North Yorkshire, except
where the female partner is nearing the upper age limit of 40. Where this is the case the referral should be sent to the PCT Exceptions Panel for consideration. The PCT will work with providers to ensure that eligible patients are still able to receive treatment before they reach the upper age limit.
Treatment is being deliberately withheld from couples until the woman approaches 40when the chances of success are reduced. The PCT has instituted an outrageous situation. I know that it has financial problems, but that path is deeply inequitable.
To be fair to the Minister, we have discussed the matter before and she has raised it before. She wrote to PCTs in June last year, when she rightly said that
persistent inequality of provision is hard to bear, and hard to understand for those affected.
The question is, what is being done about that? The inequalities persist, and some are being exacerbated by the way that PCTs respond to financial circumstances.
Will the Minister tell us how the Government are to respond? If she says that they are dropping the guidance that the Secretary of State gave in February 2004, that April 2005 meant one cycle of IVF and that in April 2008 the NICE guidelines will be available as intended, it will not cause every PCT to adhere to the guidelines straight away, but it will incorporate into the Healthcare Commissions scrutiny of PCTs the question whether they comply with NICE guidelines. The enforcement of NICE guidelines is important.
Back in February 2004, the Prime Minister said not only what the hon. Member for Romsey said he said, but added:
In the longer term, however, we think that we can extend it
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