In Vitro Fertilisation (IVF) Funding (P.20/2024): amendment

STATES OF JERSEY

IN VITRO FERTILISATION (IVF) FUNDING (P.20/2024): AMENDMENT

Lodged au Greffe on 23rd April 2024

by the Minister for Health and Social Services Earliest date for debate: 30th April 2024

STATES GREFFE

2024  P.20 Amd.

IVF VITRO FERTILISATION (P.20/2024): AMENDMENT

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1  PAGE 2, PARAGRAPH 1 –

After the words: “funding for In Vitro Fertilisation (IVF) treatment,” for the word “removing” substitute the word “replacing”.

2  PAGE 2, PARAGRAPH 1 –

For the words “and ensuring any new funding model reflects National Institute for  Health  and  Care  Excellence  (NICE)  clinical  guidance,  and  to  ensure” substitute the words “bringing forward new access criteria that accord with good clinical standards and which has been subject to consultation, and ensuring”

 MINISTER FOR HEALTH AND SOCIAL SERVICES

Note:  After this amendment, the proposition would read as follows –

THE STATES are asked to decide whether they are of opinion −

to request the Council of Ministers to commit to improving funding for In Vitro Fertilisation  (IVF)  treatment,  replacing  the  current  means-tested  model, bringing forward new access criteria that accord with good clinical standards and which has been subject to consultation, and ensuring that such funding is included within the Proposed Government Plan 2025-28.

REPORT

The  proposition  brought  forward  by   Deputy   Stephenson  clearly  articulates  the challenges that Islanders face in funding IVF and presents a compelling case for removing  the  current  income  threshold and  bringing  forward a  non-means  tested scheme.

It is acknowledged that infertility is a disease and that means testing access to IVF is out of the step with the principles for access to IVF in some comparable jurisdictions (for example UK), albeit most jurisdictions limit access to publicly funded IVF through some mechanism.

For this reason, we accept Deputy Stephenson ’s proposal that we should replace the current means-tested model which imposes a unrealistically low income threshold. IVF is, nevertheless, an expensive procedure, regardless of whether it is funded by individuals or by the public and for this reason, we propose P20/2024 is amended to remove the commitment to funding a model of services  that accords  with NICE guidance until we have developed, and consulted on, full access criteria.

Deputy Stephenson ’s proposition references the requirement for access criteria stating that: “Demand [for IVF] could increase with improved funding, but that [increase in demand] would be balanced by the access criteria which would mean not all of those patients would qualify for funding, certainly not all at the same time.

It is contended that the Assembly should not commit to funding a service that is in accordance with NICE guidance (which in simple terms currently means funding up to 3 full IVF cycles for women aged up to 40) until the Assembly has had an opportunity consider access criteria and costs in the round.

NICE guidelines

NICE guidelines for IVF currently set out that:

• Woman aged under 40 should be offered 3 full cycles of IVF if:

• they have been trying to get pregnant for a total of 2 years OR
• have  been  using  artificial  insemination to  conceive  and  have  not become pregnant after 12 cycles (at least 6 cycles should have been using intrauterine insemination)

• Woman aged 40 to 42 years should be offered 1 full cycle of IVF if the above apply and they have never had IVF treatment before and tests show their ovaries would respond to fertility drugs.

NICE IVF guidelines are non-binding advice intended to assist the NHS in exercising its duty to deliver services. NHS Trusts are not compelled to deliver against those guidelines.

In England funding decisions for health services are made by Integrated Care Boards (ICBs)  and  whilst  the  Department  of  Health  and  Social  Care  expects  ICBs  to commission fertility services in line with NICE guidelines, this does not happen on the

basis of cost. In England only 3 out of 42 ICBs offer 3 IVF cycles, others offer just 1 or 21.

Cost considerations are relevant to Jersey given existing and future pressures on our health and care services.

In Scotland IVF is provided in accordance with NICE guidelines. More cycles of NHS funded IVF are provided in Scotland than in England or Wales (as a proportion of the population) but the additional access criteria that are applied in Scotland work to restrict demand – as Deputy Stephenson notes are a function of such criteria.  

Access criteria in Scotland are, in some cases, more stringent than the published criteria

of English ICB’s. For example, NHS IVF treatment is not available to single women in Scotland, but may be available to single women in some areas of England. The Scott ish criteria can include:

 

Diagnosis	Subfertility with an appropriate cause of any duration - all couples  OR  Unexplained  subfertility  of  two  years  – heterosexual couples Unexplained subfertility following six cycles of donor insemination – same sex couples
Residency	Place of residency
Stable relationship	Couples must have been cohabiting in a stable relationship for a minimum of two years.
Sterilisation	Neither partner to have undergone voluntary sterilisation or who have undertaken reversal of sterilisation
Biological child	Couples where only one partner has legal parenthood of a child  (or  a  biological  child)  can  access  NHS  funded treatment as long as all other access criteria are met in full. Same sex couples will not be eligible if they already have a child  in  the  home  and  both  have  consented  to  legal parenthood of that child
Smoking	Both partners must be non-smoking for at least three months before  treatment  and  couples  must  continue  to  be  non- smoking during treatment
Drugs and alcohol	Both  partners  must  abstain  from  illegal  and  abusive substances Both partners must be Methadone free for at least one year prior to treatment Neither partner should drink alcohol prior to or during the period of treatment
Welfare  of  the children assessment	Assessment will be undertaken to determine whether the prospective child is likely to face serious medical, physical or psychological harm.

1 NHS-funded IVF in England - GOV.UK (www.gov.uk)

NOTE: NICE are scheduled to publish new IVF guidance in May 2025. It is not currently known which elements of their guidance may change but NICE have stated that they are reviewing the following matters:

• IVF access criteria, including potential expansion of the definition of people with health-related fertility problems to include single people, people who are gender transitioning / have gender transition and people using a surrogate, in addition to heterosexual couples, people in a same sex relationship and people preparing for cancer treatment that wish to preserve their fertility, as per the current guidelines
• Procedures used in IVF treatment, including intracytoplasmic sperm injection (“ICSI”) and frozen egg transfer which incur additional cost.

Financial and staffing implications Cost of enhanced IVF provision in Jersey

P20/2024 sets out estimated additional costs that would be incurred by the Assisted Reproduction Unit if the existing means testing for IVF was to be removed. These costs are difficult to estimate but P20/2024 reasonably estimates additional expenditure of £387,600 per year (based on 68 cycles of IVF provided in 2023) to £755,300 per year (based on 10-year average of 129 cycles per year) at a per cycle cost in the region of £4,800[2] or £6,600 if ICSI is required.

Those costs do not include:

• the IVF medication (such as medications for ovarian stimulation) which are currently provided for free by HCS to all IVF patients at an approximate cost of £1,000 per IVF cycles
• travel and accommodation costs associated with accessing UK IVF clinics (which are not currently provided to IVF patients but should be considered as part of the new access criteria)
• the additional costs associated with use of frozen as opposed to fresh embryos. It is estimated that use of frozen embryos occurs in approximately 35% of IVF cycles currently facilitated via HCS at an additional cost of £3,290 plus an additional medication costs of £250 per cycle.

As set out above, IVF is provided in accordance NICE guidelines in Scotland. In 2021, a total of 2,924 IVF cycles were funded by the NHS in Scotland which would equate to around 87 cycles per year based on the population of Jersey, so within the mid-range of P20/2024 calculations IF additional access criteria were applied which mirrored those in Scotland (which would, for example, exclude single women).

 

87 cycles of IVF (50% IVF / 50% ICSI)	c. £495,900
Use of frozen embryos for 35% of 87  IVF  cycles  (not  including medication costs)	c. £101,181

 

Medication costs for 19 IVF cycles (87 cycles – 68 cycles for which HCS funded medication in 2023)	c £19,000
Medication cost for use of frozen embryos  (35%  of  additional  19 IVF cycles)	c. £1,663
Total	Approximately £617,744 additional funding per year for HCS assisted reproduction unit per year

However, caution is required when estimating projected increases on such basic data which does not take account of variable factors such as:

• the age of women presenting for IVF in Jersey when compared to Scotland. If factors such as cost of living is driving up the age at which women in Jersey are seeking to have a family:

• they may be potentially more likely to require IVF in the first instance
• they may require more cycles of IVF (ie. the full three cycles as opposed to 1 or 2 cycles which would further drive up costs)

• any additional HCS overhead costs if an increased number of patients requires increased staffing etc.

Furthermore, as set out above, we do not know the cost implications associated with the ongoing review of NICE guidance.

Next steps

It is proposed that new access criteria should be developed before a decision is taken as to whether to fund up to three IVF cycles for all infertile people under 40 or for some groups of infertile people and / or whether to limit the number of funded cycles for some groups of people in order to manage costs. The access criteria will be subject to consultation.

In so doing, we will ensure that any IVF service funded by the Government of Jersey accords with good clinical standards, even if it does not provide up to three publicly funded IVF cycles for all people.

A business case will be brought forward to the 2025 Government plan which will include  increased  funding  for  the  new  access  criteria.  States  Members  may  then determine  whether  to  agree  the  proposed  IVF  funding  provision  (alongside consideration of all other public services improvement proposals) or bring forward an amendment to further increase funding.

Women’s health survey

On 20 February, GoJ launched a women’s health and wellbeing survey3. The survey closes on 21 May and findings will be available during the Summer.

The survey asks Islanders to tell us which services Government should prioritise for improvement,  including  whether  we  should  priorities  services  related  to  female

3 Women's health and wellbeing survey (gov.je)

reproductive health. The results of the survey will help inform the decisions of Ministers and Assembly members in relation to additional investment in IVF.

Where a CRIA has been prepared:

A Children’s Rights Impact Assessment (CRIA) has been prepared in relation to this proposition and is available to read on the States Assembly website.