2005

1. INTRODUCTION TO HEALTH
ECONOMICS
HT4 SO2
Assignment No. 2
University of Glamorgan
Enrolment No. 04155084
23 November 2009

2. Introduction to health Economics. Assignment 2. 04155084
NHS provision of fertility treatment.
Background
One in six couples may experience problems with their fertility at some point of their
fertility lives.1 In UK fertility treatments are tightly regulated by The Human
Fertilisation and Embryology Authority (HFEA), a statutory non-departmental
Government body that licenses, controls and regulates all aspects related to fertility
treatment, including research.2
Fertility treatment came to the public arena in 1978, when in-vitro fertilisation (IVF)
was introduced. Since then, thousands of pregnancies have been achieved worldwide
using this technique.3 IVF is the most expensive fertility treatment and it is used when
other approaches have failed. IVF costs around £ 3,000 privately and it is usual for a
woman to need three or more cycles before becoming pregnant. At present, most of
the 27,000 IVF treatments a year received by couples are carried out in the private
sector.
With IVF becoming more and more available, in the last few years there has been a
heated debate around fertility treatments. Whether these treatments should be offered
free by the NHS or not and if so, how many cycles of treatment should be provided
has been points of controversy and fertility treatments have become an important
issue for decision makers. In UK, couples with fertility problems have been
particularly concerned about ‘postcode prescribing’, by whom some local health
authorities (PCTs and LHBs) have been offering fertility treatment while others,
sometimes very close geographically, have been denying the same coverage.
To try to resolve some of these questions, in late 2000, Alan Milburn, then secretary
of state for health asked The National Institute for Clinical Excellence (NICE) to
produce guidelines about provision of fertility treatment in the NHS. NICE is an
independent NHS organisation created in 1999 to ‘make recommendations on
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3. Introduction to health Economics. Assignment 2. 04155084
treatments and care using the best available evidence’. NICE produces cost
effectiveness guidelines in three areas of health: technology appraisals, clinical
guidelines and interventional procedures.4 It was hoped that NICE was going to
produce guidelines based on clinical evidence of effectiveness of the treatments and
likely success in men and women of different ages, ending geographical inequality of
access and ensuring a consistent approach.5
NICE produced the guidelines in 20046 in conjunction with the National
Collaborating Centre for Women’s and Children’s Health (NCCWCH) to address the
‘technical’ aspect of fertility treatment. NICE looked at effectiveness and economic
aspects of fertility treatments. The guidelines included the following key
recommendations:
• ‘Screening all women for chlamydia before they undergo procedures to check
if their fallopian tubes are blocked’.
• ‘Offering six cycles of intra-uterine insemination (IUI) to couples with:
Unexplained fertility problems, or slightly abnormal sperm count, or mild
endometriosis’.
• ‘Offering three cycles of stimulated IVF to couples in which the woman is
aged between 23-39 who have an identified cause of their fertility problems or
unexplained fertility of at least three years’.7
The new health secretary, John Reid, welcomed the guidelines saying that the
guidelines ‘may lead the way for thousands more women to access infertility
treatment’. He also explained that although it was not possible to implement the
guidelines straight away the Department of Health wanted to ensure a national level
of provision. He also announced that by April 2005 he wanted all PCTs to offer at
least one full cycle of treatment to all eligible women and that in the future his
department was going to try to implement the full guidelines recommendations.8
Why this issue needs to be addressed from the economic perspective
I believe the first decision that needs to be taken regarding fertility treatment is
whether the NHS should provide it for free. Whether subfertility is a medical or a
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4. Introduction to health Economics. Assignment 2. 04155084
social problem is a question that needs to be answered and a political o even social
decision needs to be made based on social values.
Some people have said that fertility treatment should not be provided by the NHS at
all as it is not a ‘medical necessity’ (not necessary to preserve the patient’s health).9
Moreover, it is an experimental and very extensive treatment and there are other more
important priorities that may be undermined by assigning resources to fertility
treatments. Other people have replied saying that people with infertility need to be
supported. In an interview for the BBC, Professor Alison Murdoch, chairwoman of
the British Fertility Society, supported the use of NHS resources and stated that
‘trauma suffered by couples unable to conceive is a legitimate call on NHS
resources’.10 Some authors have even suggested that there is a value placed in going
though IVF even if this is not successful.11
Once the decision about providing fertility treatment free though the NHS has been
taken, the next step is to decide how many resources the NHS should invest on
fertility treatment. Resources are scarce and choices are inescapable, fertility
treatment will be competing for those NHS scarce resources with other NHS
services.12
The way NHS resources are allocated can be decided in different ways, political
lobbying, social pressure, a media campaign, pressure from the medical
establishment, but by taking the decisions from a health economics point of view we
use a framework that allow us to reach conclusions about how these resources can be
allocated.13 Health economics uses specific techniques to try to provide a consistent
approach about how decisions can be taken.
It can be argued that fertility treatment should not be addressed from an economic
perspective and doing so is unethical. How can we put a price to a new life? Life has
no price and everybody should have the right to free fertility treatment regardless of
the cycles needed and the money spent. This argument can be answered from health
economics point of view saying that resources in the NHS are finite and resources
used to provide fertility treatments will not be used to provide other NHS services
(opportunity cost). We have to be aware of the sacrifice that we will do by assigning
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5. Introduction to health Economics. Assignment 2. 04155084
resources to fertility treatment.14 What is unethical is to allocate scarce NHS resources
without thinking about the consequences and the opportunity foregone that this
decision will have on other NHS services. By using health economics we want to try
to allocate resources in a fair and equitable way.
Health economics can inform policy makers but can also help local PCTs and LHBs
in the decision-making process.
Health economics can also help deciding which are the extra benefits (marginal
benefits) for example of expanding the IVF programme providing more than the three
cycles recommended by NICE. The health economists will say that we have to be
aware that the costs of IVF increase rapidly because with each cycle in which
fertilisation fails, the probability of becoming pregnant declines.15 If we want to
expand the programme we have to be aware that this is going to affects other services
(opportunity cost).
How this issue can be addressed from the economic perspective
One of the main challenges when measuring the value of fertility treatment is how it
can be measured and compared with other health spending priorities.16 Health
economics can provide tools to help comparing different interventions; some of these
tools are the methods of economic evaluation.
Cost Benefit Analysis (CBA)
This economic analysis assigns monetary value to all costs and all benefits of an
intervention. The CBA examines whether and objective is worth pursuing (allocative
efficiency).14 Tries to answer the question: ‘should we do it?’ ‘Is it worth spending X
to get the benefits Y given the opportunity cost?’
CBA is not perfect; it has the difficulty of having to give monetary value to benefits
and health consequences. CBA has to use implied values and has to value things that
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are intangible like life or death. CBA normally uses market prices when they are
available but it has to do some assumptions too.17
CBA can help when addressing the question of whether fertility treatment should be
provided. I mentioned that I think that this is a political or even social decision but
CBA can help in deciding whether we should assign resources to IVF. It is very
important that with the CBA we decide which perspective we are taking: NHS, public
sector or society. It is obvious that from a NHS perspective IVF is a very expensive
treatment but from a societal perspective it may be worth providing it.
Cost Effectiveness Analysis (CEA)
This economic analysis is used to compare interventions that are similar, have similar
outcomes and therefore can be measured in identical units. With CEA we rank
alternative ways to pursue a given objective. CEA does not challenge the decision of
whether we should pursue an objective but tries to get the greatest gain for expense
analysing whether resources are used efficiently (technical efficiency). CEA addresses
the question of ‘how’ should we achieve an objective at the lowest cost or which is
the most effective way to achieve this objective.13
CEA has also some weaknesses; for example can not analyse interventions that have
several outcomes. CEA generally adopts a health service perspective (lecture notes, M
Longo, 2005).
CEA can be of a great help when taking decisions about how fertility treatment should
be provided. Once the decision about providing fertility treatment has been taken,
CEA can help in deciding how we can provide it in the most effective way.18 This is
what NICE did with the Guidelines produced in 2004. NICE analysed many aspects
and techniques around fertility treatment and made recommendations about how to
provide fertility treatment based on their effectiveness and costs. IVF was one of these
aspects analysed. For example, based on effectiveness, NICE recommended providing
the first three cycles of IVF.6
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It is important that we know what we want to achieve when doing a CEA (outcome).
In the case of fertility treatment it seems clear that the outcome is pregnancy but
authors of CEA should state how they define pregnancy (biochemical pregnancy,
clinical pregnancy, ongoing pregnancy, live birth rate, maternity rate, take-home baby
rate), if not, direct comparisons with different techniques will be difficult.19 The most
cost effective infertility treatment will be the one that achieves pregnancy (with a
healthy baby and healthy mother) at a lower cost.20 A technique o programme that can
provide fertility treatment for many patients at a very low cost but it is not achieving
pregnancy or does not produce healthy babies and mothers is not cost-effective. If we
have a programme or treatment that is both more effective in achieving pregnancy and
more costly we do not have an answer to the cost effectiveness question but we can
show how much extra it will cost to achieve an extra pregnancy (incremental
analysis).17
Cost Utility Analysis (CUA)
This economic analysis compares interventions that produce different consequences
in terms of quantity and quality of life. It is very useful when quality of life is an
important outcome. Quality of life can sometimes be a more important outcome than
the results of a treatment. CUA uses a multidimensional measure of health called
QALY (quality-adjusted-life-year) that allows comparisons across interventions.13
CUA has some problems; technology changes quickly and it is difficult to compare a
current study with one done several years ago. CUA has also problems with equity
and it is well known that is not fair with the elderly.
Despite the fact that NICE usually takes decisions based on QALYs (normally accepts
treatments that cost less than £30,000 per QALY) I could not find any single CUA on
fertility treatment during my literature review; most of the studies are CEA.18 19
Quality of life must be a very important factor in measuring the outcomes of fertility
treatment and I am very surprised this has not been taken into account. I am aware of
the fact that the treatments with a higher pregnancy success will attract the higher
number of QALYs but it is possible that just the fact of getting fertility treatment
could increase the quality of life of the infertile couples.
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8. Introduction to health Economics. Assignment 2. 04155084
Bibliography
Word Count: 1,985 (excluding bibliography)
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