This week the Scottish Government announced that couples who need help to conceive will benefit from an IVF shake-up.
The health minister, Michael Matheson, said the new rules would provide “fair, reliable and faster access” to treatment; that provision of IVF would no longer vary depending on where you live; and that £12 million would be invested in driving down waiting times over the next three years. Couples who have complained of long waiting lists and campaigned against an IVF postcode lottery have welcomed the news – and rightly so.
However, the new criteria come with restrictions: treatment won’t be offered to women who are obese or to couples who drink and smoke. They will be put on a “holding list” until they can prove they’ve lost enough weight, smoked their last cigarette and agreed to give up alcohol. Lifestyle not medical need, will determine who are the deserving and the undeserving.
The only part of this that is surprising – the rationing of care based on patients’ lifestyle choices – is that it has taken until now to officially declare it is a policy the NHS is pursuing; that it may well be the future. And given the funding dilemmas the health service faces, denying fertility treatment to those deemed “less viable”, makes some financial sense. Although stopping smoking is not a medical requirement for IVF to work, it is thought to reduce the chances of success. The same applies to women with a higher body mass index.
The facts however, which not all doctors are even agreed upon, do not make the rationing of treatment any easier to accept. Infertility must surely be the cruellest of conditions. For couples already prepared to do anything to have a child, there are now simply more hoops to jump through. But the truth is, health boards have already been making decisions about IVF based on lifestyle for some time. Last year NHS Fife announced that it would no longer give fertility treatment to obese women or to smokers. The latest guidance from the National Infertility Group simply applies the same treatment criteria across the NHS.
But is denying people access to treatment a slippery slope? Certainly the concern must be that such rationing is discriminatory – that the NHS is in danger of providing a second-class service to people leading less healthy lifestyles; that they are not only being judged, but punished.
More than a quarter of primary care trusts in England brought in new lifestyle restrictions last year, and data revealed that people were being denied not only IVF treatment but routine surgery. In some cases there may have been a genuine clinical justification for limiting treatment on the grounds of weight, but the accusation was that some hospitals had been blocking access to surgery for smokers or the obese, in an attempt to save money.
And if weight can be used as a bar to treatment, what about age? It already poses the biggest moral dilemma for an NHS able to pick and choose who it treats for infertility. As women wait longer to have families, the demand for IVF has increased hugely. Under the new rules, women under 40 will be guaranteed two free cycles of fertility treatment. Women aged between 40 and 42 will be eligible for one cycle only – and only – if they have never previously undergone treatment.
Earlier this year the National Institute for Health and Clinical Excellence (NICE) caused a rumpus when it recommended that older women should be given access to IVF in England and Wales. However, with the majority of trusts already struggling to meet current guidelines, increasing the upper age limit from 39 to 42 is unlikely to become the norm, particularly given that the NICE recommendations are just that – recommendations. But it could be argued that a healthy, forty-something woman should be given priority over a younger, overweight smoker – if access to treatment is based on lifestyle.
Money is also, of course, an over-riding factor. The NHS already rations what it does; now it has simply extended that to IVF. Fertility treatment is not an automatic right; care should be prioritised. And although the new rules will be seen by many as tough but fair, that won’t make it any easier to accept if you are overweight or a smoker.