Restricting access to non-urgent services


Summary

Further to our recent public consultation, the Clinical Commissioning Group (CCG) Board has decided to make no change to our policy on male vasectomy, but to change our policies on female sterilisation and fertility services.

Please see below for more information about these decisions.

Thank you again to everyone who took part in our consultation. To find out what people told us, please see the consultation summary below.

 

In November 2017, we proposed restricting access to three services in Bath and North East Somerset (B&NES): vasectomies, female sterilisations and fertility treatment.

We consulted widely on these proposals from November 2017 until the end of January 2018.  Thank you to everyone who participated and shared their views with us.

What the public told us

We have now reviewed all of the feedback we received. To find out what people told us, please read our consultation summary or full consultation report and ‘consultation in numbers’ infographic on the right hand side of this page.

Please note, this information can all be made available in a range of languages, large print, Braille, or on CD/tape. To request an alternative format, please email banes.yourvoice@nhs.net or call 01225 831 800.

What happened next?

A summary of the public’s feedback was included in a report, with recommendations, which were presented to the Clinical Commissioning Group (CCG) Board on Thursday 8 March 2018. To read the recommendations report, please download it from the right hand side of this page.

The final decision, on the basis of public feedback and the likelihood of incurring greater costs associated with unplanned pregnancies than the costs incurred by vasectomy, was to continue to fund vasectomies. Similarly, women will be able to access NHS-funded sterilisations if they have first explored alternative, less invasive forms of contraception.

With regard to fertility services, the Board balanced public feedback with clinical evidence on IVF success rates and the CCG’s financial decision. You can read more about the rationale in our news story.

The Board decided to change the CCG’s policy on fertility services so that:

  1. The female partner receiving treatment must be aged between 23 and 37 years
  2. The male partner of the woman receiving treatment must be aged 55 years or under
  3. The female partner receiving treatment must have a body mass index (BMI) in the healthy range for women wanting to conceive, of 19–30
  4. The male partner of the woman receiving treatment must have a healthy BMI of under 30
  5. Heterosexual couples must have been trying to conceive for at least 2 years where the female partner is aged 35 years or younger, and 1 year where the female partner is aged 36 -37 years.

Please note: the policy changes came into force on 2 June 2018. 

 

The reason we proposed restricting these services is that the population of (B&NES) is growing and changing and this is having an unprecedented impact on the local NHS budget, which is now significantly stretched. We need to make cost savings to help us meet our duty to live within our means, and not get into debt.

This financial situation has driven us to make several changes to the health services we commission, two of which started in early 2017 when we stopped funding prescriptions for gluten-free foods and over-the-counter medicines for short term ailments.

However, while the changes we have made so far have strengthened our financial position, we are still facing a possible deficit without taking further action. This is why we have had to consider restricting other non-urgent services.

There is more background information if you click on the next tab along entitled ‘Frequently Asked Questions’ and an extended version of these frequently asked questions is available to download on the right-hand side of this page.

Our proposals included:

  1. Stopping funding male vasectomies and female sterilisations except in exceptional circumstances.
  2. Changing the access criteria for fertility treatment to the following:
Current criteria Proposed changes
Female partner is aged 23-40 years Female partner is aged 23-35 years
Female partner has a BMI of 19-30 for at least 6 months prior to treatment. Woman with polycystic ovaries with a BMI of 19-33 will be eligible Female partner has a BMI of 19-30 for at least 6 months prior to treatment. This applies to all women.
No age limit for male partners. The male partner (in the case of heterosexual couples) is aged 55 or younger.
No BMI criteria for male partners. The male partner (in the case of heterosexual couples) has a BMI of 30 or less.
No criteria related to duration of infertility/time trying to conceive. Duration of infertility of at least 2 years.

We will continue to fund one full cycle of IVF treatment and one frozen cycle for those who meet the eligibility criteria.

Restricting access to non-urgent services

We are the NHS organisation that not only monitors and coordinates but also commissions – or purchases – health services on behalf of everyone living in Bath and North East Somerset (B&NES).

We are a membership organisation formed of the 26 GP practices across B&NES.  For many patients, their local GP is their main point of contact with the NHS and it is the GPs’ clinical expertise and patient insight that helps the CCG to ensure health services are the best they can be. But GPs are not doing this alone. Within the CCG, we work with a team of healthcare professionals and patient representatives to plan and deliver services.

We are undertaking a public consultation on proposals to restrict access to three services that we commission.

These are:

Fertility treatment

We are proposing to change the criteria by which fertility treatment is accessed in B&NES. The changes will limit the number of residents who are then eligible for NHS-funded treatment according to their age, body mass index (BMI) and the length of time they have experienced infertility. See the Proposed Criteria Table in the question ‘What are the proposed changes in criteria to access fertility treatment?’ for full details of the specific changes.

Vasectomy and sterilisation

We are proposing to stop funding for both male vasectomies and female sterilisations in all but exceptional circumstances.

Like many areas of England, BaNES CCG is facing significant financial challenges as our population grows, changes and consequently puts more demand on services. Our health budget for B&NES is being stretched, and as a result, we need to make savings in order to live within our allocated budget.

Our target is to save £10.2 million by the end of the 2017/18 financial year to be able to avoid a deficit. To do this, we are working closely with our GP members and partners across the local health and care sector to transform primary and community services so that more people can be treated at home rather than in hospital.

There are also lots of things we can all do to help make sure NHS resources are spent in the best and most effective way possible, and these include picking the right service when you need help and staying as fit and healthy as possible.

You can read more about our financial situation and our savings plans on our website.

Because of the financial challenges we are facing, we are having to consider making difficult decisions about the services we currently offer and whether reducing them could help us achieve our statutory duty to live within our means.

Because of our financial situation, we have already taken steps to reduce inefficiency and waste in B&NES and have implemented a programme of work at the CCG that is helping us contain our costs.

Early in 2017, we took the decision to stop funding gluten-free products and over-the-counter medicines for minor ailments on prescription, after a period of consultation with the public. We are also part of a regional consultation that is asking the public for their views about who would benefit most from NHS-funded non-urgent patient transport.

We are considering these three services in particular after looking at other CCGs in the country that have made savings by reducing access to non-urgent services that impact small numbers of individuals.

The current fertility services policy can be found on our website here.

The current vasectomy policy can be found on our website here. There is currently no female sterilisation policy.

The amount we spend on fertility treatment varies each year, however the total spend in recent years has been between £222,000 and £319,000.

The total spend in the previous financial year on male vasectomies and female sterilisation was approximately £49,000. We anticipate that stopping funding for sterilisations except in exceptional circumstances will offer financial savings of up to £40,000. This equates to the majority of the CCG’s current annual spend on sterilisation and still allows treatment in some exceptional circumstances.

 

Our proposals will affect people who are registered with a GP in B&NES and who want to access fertility treatment or sterilisation.

If you are registered with a GP outside of the B&NES CCG area, these changes will not affect you and you should check with your local CCG to find out whether they will fund treatment for you.

 

The consultation was originally open for seven weeks from 8 November to 27 December 2017.  However, following feedback at a public meeting on 8 January 2018, the consultation is reopening from 11 to 31 January to give everyone more opportunity to share their thoughts and opinions on the proposed changes.

We would like to get as wide a view as possible from as many people as possible. In particular we are interested in hearing from anyone who may be affected by the proposals.

You can fill in our surveys online here:

Fertility services survey
Vasectomy and sterilisation survey

You can download paper copies of the surveys on the right hand side of the ‘About this project’ page. The surveys can be made available in a range of languages, large print, Braille, or on CD/tape. To request an alternative format, please email banes.yourvoice@nhs.net or call 01225 831800.

You can also email, write or call us with your thoughts. Our contact details are:

Communications & Engagement Team
Bath and North East Somerset Clinical Commissioning Group
St Martins Hospital
Clara Cross Lane
Bath BA2 5RP

Or call 01225 831 800 or email banes.yourvoice@nhs.net.

If you would like us to come and speak with your local/community group, please get in touch with your contact details.

All the feedback that we have received since November will be collated into one report, which will be presented to the CCG Board for a final decision to be made.

The full consultation evaluation report and details of the final decision will be published on our website.  This information will also be shared with the local health community to ensure that everyone who took part in the consultation can find out what people said and how the CCG has responded.

For more information, please contact banes.yourvoice@nhs.net or call 01225 831 800. You can also find out more here on our website.

Fertility treatment that is funded by the NHS includes in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) treatment. The proposed changes apply to both types of fertility treatment.

During IVF, eggs are removed from the woman’s ovaries and left to fertilise with sperm in a laboratory or clinic. The fertilised egg, called an embryo, is then returned to the woman’s uterus (womb) to grow and develop into a baby.

In some cases, eggs may need to be injected individually with a single sperm. This is called ICSI. It can be carried out using a woman’s own eggs and her partner’s sperm, or donor eggs and/or sperm.

The table below summarises the current criteria and the proposed changes to criteria:

Proposed Criteria Table:

Current criteria Proposed change
Female partner is aged 23-40 years Female partner is aged 23-35 years
Female partner has a BMI of 19-30 for at least 6 months prior to treatment. Woman with polycystic ovaries with a BMI of 19-33 will be eligible Female partner has a BMI of 19-30 for at least 6 months prior to treatment. This applies to all women.
No age limit for male partners. The male partner (in the case of heterosexual couples) is aged 55 or younger.
No BMI criteria for male partners. The male partner (in the case of heterosexual couples) has a BMI of 30 or less.
No criteria related to duration of infertility/time trying to conceive. Duration of infertility of at least 2 years.

We will continue to fund one full cycle of IVF/ICSI and one frozen cycle for those who meet the eligibility criteria.

The proposal to restrict access to fertility treatment to women aged 23–35 years is based on data both from B&NES and nationally that indicate the chance of a live birth following IVF treatment falls after 35 years (NICE Clinical Guidance [CG156] 1.10.1.1 and Figure 2).

For example, NHS Choices cites the success rates (percentage of live births) of IVF in 2010 as:

  • 32.2% for women under 35
  • 27.7% for women aged 35-37
  • 20.8% for women aged 38-39

This means that NHS-funded treatment would be focused on the age group where it is likely to have the most success.

The age of the female partner has a larger impact on fertility than the man’s age but studies suggest that there is a decline in the sperm count in older men and their sperm is more prone to genetic errors.

Body mass index (BMI) is a measure of body fat based on your weight in relation to your height, and applies to most adult men and women aged 20 years and over.

We are proposing that all women should have a BMI of 19-30 for six months before any fertility treatment to make access to fertility treatment more equitable across B&NES.

NICE Guidance CG156 states that women with a BMI of 30 or over should be informed that they are likely to take longer to conceive and those with a BMI over 30 who are not ovulating increase their chances of conception by losing weight.

NICE Guidance CG156 also states that in addition to women, men who have a BMI over 30 are likely to have reduced fertility.

We are therefore proposing to introduce this criterion to mirror the advice given to couples who are trying to conceive naturally.

“Duration of infertility” means the length of time that a couple has been trying to conceive naturally without getting pregnant.

Clinical evidence suggests that over 80 per cent of women aged under 40 years will conceive naturally within the first year of trying, and about half of those who do not, will conceive during the second year. This gives a cumulative pregnancy rate of over 90 per cent.

The two-year duration of infertility we propose allows sufficient opportunity for a couple to conceive naturally, without the need for fertility treatment.

It is not possible to determine exactly how many people these proposals will affect as the figures of those undergoing treatment vary from year to year. However, if the proposals are implemented, they are estimated to affect approximately 50 per cent of patients seeking NHS funding for fertility treatment. This would amount to approximately 30 couples per year in B&NES.

For further information and advice about fertility, individuals should speak to their GP and/or consult NHS Choices https://www.nhs.uk/Livewell/Fertility/Pages/Fertilityhome.aspx.

As with our current policy, patients who are not eligible for treatment may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule.

Individual cases will be reviewed at the CCG Exceptional Funding Panel upon receipt of a completed ‘individual funding request’ application form from the patient’s GP, Consultant or Clinician. Applications cannot be considered when submitted by patients themselves.

Exceptional circumstances will be considered on their own individual bases, but include diagnoses of absolute infertility that preclude natural conception e.g. azoospermia or bilateral fallopian tube blockage.

If you have been referred for or are undergoing treatment prior to the implementation of any restrictions, you will not be affected by any policy changes.

Sterilisation is a permanent method of birth control that can be carried out in both men and women.

Male sterilisation is carried out via a procedure called a vasectomy; this is done by cutting and sealing or tying the vas deferens (the tube that carries sperm from the testicles to the penis).

Female sterilisation is done by cutting, sealing or blocking the fallopian tubes, which carry eggs from the ovary to the uterus.

We are proposing that B&NES CCG will no longer offer NHS-funded treatment for either male vasectomies or female sterilisations under normal circumstances. Patients with exceptional circumstances will still be able to apply for funding through a route called an individual funding request.

GPs can give advice about alternatives to vasectomy and sterilisation, including long-acting reversible contraceptives. There is also information and advice on the NHS Choices website: https://www.nhs.uk/Conditions/contraception-guide/pages/contraception.aspx.

In the past year in B&NES there were 147 vasectomies and 16 female sterilisations.

If you have already been referred for or are undergoing treatment prior to the implementation of these changes, you will not be affected.

The cost of fertility treatment can range from as much as £2,000 to £6,500 as there are a range of treatment options and fertility clinics set their own costs just like any other private healthcare provider.  But to help give an indication of charges, locally, the cost of one cycle of IVF is around £3,500.

The cost of a self-funded vasectomy under a local anaesthetic ranges between £450 and £900 as private health providers set their own charges for treatment. Occasionally a patient will choose to have a vasectomy under general anaesthetic which will be more expensive to cover the cost of the anaesthetist and drugs.