Dilemma: Prescribing fertility treatment on the NHS for self-funding patients
A consultant gynaecologist is seeing a couple for secondary infertility. Both have children from previous relationships, so, according to the local PCT service restriction policy, are not entitled to referral for NHS treatment. They are self-funding, so, to help ‘minimise costs’, the consultant asks if you will arrange a hysterosalpingogram for the female partner and whether you will prescribe fertility treatment, if necessary – on his instruction – on the NHS.
It is only appropriate to refer a woman for a hysterosalpingogram once male factor infertility has been ruled out
Many GPs don’t have direct access to hysterosalpingography; I certainly never have in 16 years in my PCT. I actually feel this is appropriate because this investigation is only required after semen analysis has been carried out in a NQAS andrology lab. It is only appropriate to refer a woman for a hysterosalpingogram once male factor infertility has been ruled out as a possible cause. Otherwise you risk subjecting a woman to a painful procedure involving radiation exposure, when the couple may already be destined to need treatment by IVF or even ICSI, in which case tubal patency is irrelevant.
As to the prescribing of infertility drugs by GPs, I do not think this is ever acceptable, even in the case of clomid, but most certainly with gonadotrophins. All these drugs need close monitoring and have potentially very serious side effects including ovarian hyperstimulation syndrome, which is a condition that most general gynaecologists would have very limited experience of managing. As such, I feel it would be inappropriate for any GP to agree to prescribe infertility drugs.
Dr Stephen Davies is a GP clinical assistant in reproductive medicine at the Royal Hallamshire, Sheffield, and a spokesperson for the British Fertility Society.
The nub of this dilemma is whether the NHS primary care budget should bear the cost
There are a number of dilemmas in this scenario: the first is to be clear on what the PCT service restriction policy states; secondly, the clinical and social exclusion criteria are applied only to licensed specialist tertiary fertility units that deliver assisted reproductive technologies, commonly IVF and ICSI. So other forms of fertility treatment may be available in primary or secondary care.
The nub of this dilemma however is whether the NHS primary care budget should bear the cost of investigation when NHS PCT criteria has already judged that the couple should self fund their fertility treatment. This is simply an exercise moving patient care costs from secondary to primary care. Historically, unrestricted primary care budgets could cope with this demand and anecdotally, I think we still do remain sympathetic, act as the patients advocate, and do all we can to help.
However if GP patient care budgets continue to be squeezed and service delivery contracts are tightened there is a risk that criteria based rationing will spill over into patient care in general practice and patients in this scenario will be asked to fund all investigations and treatments linked to their problem, no matter which part of the NHS system cares for them.
An additional dilemma is that GPs may not have direct access to hysterosalpingography (HSG) through local commissioning arrangements. If they do, the role of HSG is to help make a diagnosis and assist the GP in their decision making process of whether to manage in general practice or refer to secondary care, tertiary care or private practice.
The issue of providing fertility treatment is a vexed one. If GPs are asked to prescribe ovarian stimulation with gonadotrophins, as part of an IVF treatment cycle, then I would not hesitate to say ‘no’ as GPs are not familiar with these drugs. Ovulation induction with clomifene is a subject for debate and beyond the scope of this response.
Dr Scott Wilkes is a GP with an interest in fertility and a senior lecturer at Newcastle University.
If this investigation is is not available or appropriate, it would be not permissible to sanction this
The overriding principles in managing patients who have access to private medicine needs to be applied here. This principle is that their access to any aspect of NHS care needs to be governed by the same principles that govern NHS patients. Thus if a patient is prescribed a drug by a private consultant and wishes for it to be prescribed under the NHS, this should be possible if this drug is what would have been prescribed had the patient been an NHS patient.
The same is true for treatment. Thus had the couple normally expected to be investigated via the female having a hysterosalpingogram, then it is appropriate that this procedure is funded via the NHS as not to do so denies the couple access to a national service they are part of. However if this investigation is purely associated with a request from a hospital specialist and is not available and/or appropriate to an NHS patient, then I would suggest it would be not permissible to sanction this.
The reason for saying this is simply that the expenditure of resource inevitably means that someone else within that population who may well be more deserving is denied use of the funding. The new world of clinical commissioning is about prioritisation of care within a fixed financial envelope.
Dr Charles Alessi is the interim chair of NHS Clinical Commissioners and a GP in Kingston.