GOVERNING BODY LEAD: Dr Naeem Iqbal REPORT AUTHOR: Niran Rehill & Livia Royle, Public Health Royal Borough of Kingston / Kingston CCG ATTACHMENT: AGENDA ITEM: 8 H RECOMMENDATION: The Governing Body is asked to ratify the enclosed updated Kingston Assisted Conception Guidelines. GOVERNING BODY MEETING DATE: 1 st July 2014 Kingston Assisted Conception Guidelines EXECUTIVE SUMMARY: This document is based on the updated NICE Clinical guideline 156 (2013): Fertility; Assessment and treatment for people with fertility problems. The updated guideline makes a number of recommendations to ensure people who are having trouble conceiving receive only the most effective treatments and in a more timely manner. When commissioning healthcare for its population, Kingston CCG, in line with the RCGP Ethical Commissioning Guidance 2011, aims to use limited resources to do as much good as possible whilst being fair. With respect to assisted conception, Kingston CCG aims to: Treat subfertility secondary to disease processes Follow NICE guidance as far as it is compatible with the CCG s resources to treat its population Treat any couple with no existing children (from either party, including adopted children), or single woman with no existing children. Limit treatment to one live birth per couple. This paper outlines the proposals put forward by the CCG working group to the CCG Governing Body for the commissioning of assisted conception services. It was important to update the previous local IVF policy so that it complies with Equality Act 2010 and is in line with the CCGs Equality Objectives for 2013-2017. The working group responsible for updating local IVF policy included representation from Kingston CCG (Lead GP), Royal Borough of Kingston (Public Health Consultant and Senior Registrar) and Kingston Foundation Trust (two Consultant Gynaecologist Leads and the Service Manager from the Assisted Conception Unit). Kingston Hospital NHS Foundation Trust representatives provided a clinical perspective and they also provided the working group with the views of their service users. The working group reviewed the previous local IVF policy for NHS-funded IVF treatment in light of NICE s updated fertility guideline issued in February 2013 and the CCG aims outlined above. Options were discussed at two Governing Body seminars prior to this final proposal. Version: Final H - 1
KEY SECTIONS FOR PARTICULAR NOTE: Below are listed the main changes from the current policy and additional points of interest, the rationale for these and how they compare to the latest NICE recommendations. Proposal 1: IVF - Age New proposal: - IVF will be funded for all women aged up to and including age 42 Change from current policy: - Current policy only funds treatment up to 39 years older women will now also be eligible Comparison with NICE guideline - This meets the NICE recommendation for age criteria. Rationale - IVF success rates have improved over the past decade. IVF is now as effective in these older women as it previously was in women aged 39 years, who have been receiving NHS-funded IVF locally for several years. It is therefore inequitable to refuse funding for these older women. Extending the age range also means that IVF will be available for more women locally. Proposal 2: IVF Number of cycles New proposal: - One cycle of IVF will be funded for all eligible women Change from current policy: - No change current policy only funds one cycle Comparison with NICE guideline - This does not meet the NICE recommendations. NICE recommend funding up to three cycles. Rationale - While receiving multiple cycles increases the chance of success for couples who fail to conceive after the first attempt, the cost of meeting the NICE guideline has been estimated at around 90,000. This 90,000 is money that has to be taken away from funding of other health services. In a resource limited NHS the CCG felt that using the limited funds available to offer treatment more widely via proposal 1 was the priority over offering multiple cycles. Proposal 3: Provision for same-sex couples New proposal: - Fertility investigation will be available to same-sex couples provided they are able to demonstrate sub-fertility. Sub-fertility for same-sex couples is defined as failure to conceive after 6 self-funded cycles of intra-uterine insemination, undertaken in a clinical setting. IVF will be available for women using IUI to conceive after up to 6 further cycles of IUI. Change from current policy: - The current policy states that IVF is available to same-sex couples who demonstrate sub-fertility but does not define what sub-fertility is, which makes the policy difficult to implement in practice. Comparison with NICE guideline - This is in line with NICE recommendations apart from stating that up to 6 further cycles are required prior to IVF NICE states all 6 cycles are required. Rationale - Kingston CCG is committed to delivering health services on equal grounds to all members of its population. Same-sex couples having trouble conceiving should have similar access to fertility services once sub-fertility has been identified. Version: Final H - 2
Other Proposals Routine funding of the following treatments is also proposed in order to increase availability of evidence-based treatments with minimal unnecessary bureaucracy. These recommendations are in line with NICE guidelines and apply to much smaller subgroups of couples with infertility. Some have historically been funded via non-routine routes. The cost implications of funding these additional treatments is small compared to the proposals outlined above: Cryopreservation and storage pre-cancer treatment Intra-uterine insemination (IUI) Donor insemination (IUI) Ovulation Induction Surgical Sperm retrieval (NICE guidelines state that surgical sperm retrieval is an effective treatment option, although there is no specific NICE recommendation regarding its use). The associated estimated cost pressures of the above changes are: Crude estimates of additional cost per annum ( ) IVF policy: IVF offer to women up to their 43 rd birthday 70,000 New assisted conception policies: Cryopreservation & storage (precancer) Intra-uterine Insemination 1,800 to 4,300 Donor Insemination (excl. same-sex couples) 1,000 Historically this was funded via IFR; slight increase in storage costs possible 0 to 2,300 Surgical Sperm retrieval 0 Historically this has been funded via IFR Ovulation Induction (500) Saving Provision for same-sex couples / women not in a partnership 5,000 to 25,000 very crude difficult to estimate demand here TOTAL: 77,300 to 102,100 Access to assisted conception services in Kingston will be improved through implementation of these proposals. The criterion regarding childlessness is maintained. To include updated NICE recommendations on a 24 month watchful waiting period. This will result in an increased cost, as the cohort of couples with unexplained fertility undergoing watchful waiting in primary care will become eligible to join the waiting list one year sooner than before. Version: Final H - 3
RECOMMENDATIONS: The Governing Body is asked to note the content of the report and support the recommendations outlined in this paper to revise the Kingston CCG Fertility Commissioning Policy. RISKS IDENTIFIED: The financial risks are outlined above. It is difficult to estimate the demand and cost for fertility services in same sex couples or women not in a partnership. Failure to gain Governing Body support will mean our policy is not in line with NICE recommendations. Because of a number of medical advances over the years, many fertility problems can be treated effectively. It is because of these new advances that we should update our guideline on fertility, ensuring that the right support, care and treatment is available to those who will benefit the most. FINANCIAL IMPLICATIONS: The financial risks are outlined above. GOVERNING BODY OBJECTIVES for 2013/14: Please indicate below all the domains which the paper provides evidence for: Domain One: A strong clinical focus and multi professional focus which brings real added value Domain Two: Meaningful engagement with patients, carers and their communities Domain Three: Clear and credible plans which continue to deliver the QIPP challenge within financial resources, in line with national requirements (including outcomes) and the local joint health and wellbeing strategy Domain Four: Proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities, including financial control, as well as effectively commission all the services for which they are responsible. Domain Five: Collaborative arrangements for commissioning with other CCGs, local authorities and NHS England as well as the appropriate external commissioning support Domain Six: Great leaders who individually and collectively can make a real difference Version: Final H - 4
EQUALITY IMPACT ASSESSMENT: This has been undertaken. Certain age groups remain ineligible for treatment; this is because effectiveness of these treatments varies markedly with age, and the age criteria selected are in line with NICE recommendations. Same-sex couples and people not in a relationship are will face financial costs with respect to self-funding initial attempts at conception in order to demonstrate subfertility. They may be able to access services more quickly than heterosexual couples. Treatment for either male or female subfertility, once demonstrated, will be treated according to the same criteria for all men and women, regardless of sexuality.. PRIVACY IMPACT ASSESSMENT: The Screening tool was completed and a full Privacy Impact Assessment is not required. Please indicate whether any engagement has been carried out regarding this service change. (tick appropriate box) Yes No If no, please state reason: Kingston CCG s previous In Vitro Fertilization (IVF) guidelines were developed by the South West London Effective Commissioning Group with lay representation from the South West London. The working group responsible for updating local IVF guidelines included representation from Kingston CCG (Lead GP), Royal Borough of Kingston (Public Health Consultant and Senior Registrar) and Kingston Foundation Trust (two Consultant Gynaecologist Leads and the Service Mmanager from the Assisted Conception Unit). Kingston Foundation Trust representatives provided a clinical perspective and they also provided the working group with the views of their service users. The final draft of the updated KCCG guidelines were shared with Kingston Healthwatch. It was also discussed at Kingston Governing Body Seminars and presented to the Kingston Integrated Governance Committee before approval was sought from the Kingston Governing Body. Version: Final H - 5
Kingston Clinical Commissioning Group Board Objectives for 2013/14 Set out below are a set of objectives for the CCG Board. The format is based on the 6 authorisation domains. Within each domain there are a small number of mission critical key objectives where the Board should collectively focus the majority of its attention. Domain one: a strong clinical and multi-professional focus which brings real added value. Continued development of the role and function of the Council of Members. Clinicians leading service change. Domain two: meaningful engagement with patients, carers and their communities. Genuinely involve patients in service design and evolution. Engagement with Healthwatch. Domain three: clear and credible plans which continue to deliver the QIPP challenge within financial resources, in line with national requirements (including outcomes) and the local joint health and wellbeing strategy. Delivery of the 2013/14 financial and service plans. Delivery of the National Outcomes Framework. Innovation. Domain four: proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities, including financial control, as well as effectively commission all the services for which they are responsible. Effective arrangements for oversight of the quality and safety of commissioned services. Compliance with statutory duties. Domain five: collaborative arrangements for commissioning with other CCGs, local authorities and the NHS England as well as the appropriate external commissioning support. Integrated commissioning of services with RBK. Effective discharge of our lead commissioning arrangements with Kingston Hospital NHS Foundation Trust, South West London and St Georges NHS trust and Your Healthcare CIC. Primary Care development. Better Services, Better Value Domain six: great leaders who individually and collectively can make a real difference. Board development. Commissioning staff development. Version: Final H - 6
KINGSTON CCG MISSION & VALUES We are passionate about your health, compassionate about your care Our task is to: and provide the good experience you deserve o the health and wellbeing of people in Kingston o the support that s available to help people look after themselves o the quality of local health services We value: We plan to achieve this by: he causes of ill health and premature death We will measure how well we do by: Version: Final H - 7