Rationing and IVF
Why one person’s essential is another person’s unnecessary – and how choices change over time
In the 1990s, the state of Oregon, in the US, decided that more people should be enrolled in its Medicaid programme. Recognising that this would increase costs, it carried out a project asking the public to prioritise healthcare procedures and treatment, and ensure that only those deemed essential would be available through Medicaid. The interesting aspect is not so much the creation of a list of treatments, or the decision about the cut-off point for funding. Instead, it is more that public (or rather, individual) views on what should be a priority changed with their personal situation.
In other words, it is very hard to be objective about what care ‘should’ and ‘should not’ be state funded, because everyone sees their own needs as a priority.
This is worth remembering in the light of the news that the availability of in-vitro fertilisation (IVF) has fallen. Just one in ten areas of England now offers the three cycles of treatment recommended by the National Institute for Health and Clinical Effectiveness (NICE) as clinically- and cost-effective. An increasing number offer no access to IVF at all, and others offer just one cycle.
Many people would deem fertility treatment to be a luxury. There is, they suggest, no ‘right’ to have a child, and people should just get over it and move on if they cannot afford to pay for private IVF treatment.
For those struggling with infertility, however, the reality is very different. When all your friends are having babies, and you desperately want one and are not able to conceive, it is hard to remain logical, or ‘just move on’. For many people, men and women alike, infertility can take a serious toll on friendships, relationships, and even mental and physical health. If the result of removing access to fertility treatment is to increase demand for mental health services, is that really a saving? If people are unable to work because of depression, that also has an effect on the economy as a whole.
Assessing the ‘postcode lottery’
NICE was set up for a reason: to ensure that treatments provided and funded by the NHS were clinically and cost-effective, and to remove the ‘postcode lotteries’ that meant that people living in some areas had access to services that others did not.
There is absolutely no doubt that there is a ‘postcode lottery’ in access to IVF. The reason that NICE recommends three cycles of treatment is because that is the number most likely to give a successful outcome. Why, then, are the vast majority of clinical commissioning groups (over 60%) offering just one cycle? Would it not be more honest to remove access altogether? This would at least be fair to everyone.
The NHS does not have unlimited resources, either human or financial. Efficiencies can only be pushed so far before they become serious cuts. Rationing is unpleasant, but are there alternatives?
Perhaps one way might be individual or family healthcare budgets, similar to health insurers’ cash plans. Individuals or small groups such as families could decide for themselves what they spent their budget on each year. In other words, they would ration their own healthcare. To a limited extent, this type of budget is already available for NHS services, but only for those receiving NHS continuing care outside hospitals.
It might be feasible to expand the scheme to cover more people, but there are good reasons why this has not been tried. The Oregon experiment is one, but probably the main one is the potential for ‘hard cases’ and bad publicity if someone unexpectedly needs a lot of healthcare in a single year. The idea of families having to choose between seeing a doctor when a child is ill and a parent’s cancer screening is also unattractive. With an insurance cash plan, of course, this would not matter, because the NHS is there to pick up the pieces if necessary. But if the NHS was also tied by personal budgets, this could lead to real problems.
Healthcare free at the point of need is not something we should take for granted. Perhaps, to guarantee it, we should be prepared to consider some rationing of services. But in what? Back to the Oregon experiment: one person’s essential is another’s unnecessary. There are no easy answers, or they would already have been found.