Stephen Pollard: Who says you have a right to have children?

IVF is more of a political and philosophical question than it is even remotely a clinical one

Reports this weekend that Nice - the National Institute for Clinical Excellence - is considering recommending that IVF treatment be made available throughout the NHS to all infertile women under 40 must seem the ultimate paradox.

Nice was set up with one of the most mislead launch promises in history: to spread excellence throughout the NHS, ending "postcode prescribing" and ensuring that all patients receive access to the "best" treatments available.

In reality, Nice was set up by Frank Dobson in 1999 to provide an independent, expert justification for the rationing that has always been fundamental to the modus operandi of the National Health Service. It was a thinly veiled attempt to provide medical cover for intensely political decisions. Not so much Nice as Nasty - Not Available, So Treat Yourself.

If the NHS was what some would like it to be - a monopoly healthcare provider - then the case for including IVF would be much stronger. But it has never been a monopoly. The de facto arrangement since 1948 has been that non-essential procedures are available either spasmodically on the NHS, or privately. Whether or not IVF treatment should be more widely available is not, as NICE would have it, a question of doing the maths. It is about two issues: what the NHS is for; and whether there is any "right" to children, the absence of which is something that the state, through the NHS, has a duty to rectify.

Eighty per cent of the 27,000 current annual IVF attempts are done privately. That's because the existing consensus is that there is no such right, and thus no such NHS duty. Forcing health authorities to provide IVF treatment means, in effect, redefining the purpose of the NHS to include the provision of all treatments, rather than just those that are clinically necessary. The NHS website defines its aims as being "to bring about the highest level of physical and mental health for all citizens, within the resources available, by: promoting health and preventing ill-health; diagnosing and treating injury and disease; caring for those with a long-term illness and disability, who require the services of the NHS". That raises more questions than it even begins to answer.

It's certainly true that, as new medical technologies emerge, so too our definitions of healthcare change. Viagra is perhaps the most obvious example. Erectile dysfunction can, in some men, have debilitating consequences across many other aspects of their lives, and a "cure" can certainly be a clinical need. For others, of course, it is merely about pleasure. Again, cosmetic surgery can often be frivolous - excessively so, as in the recent reports of some women having their toes shortened to fit in to fashionable shoes. But it can also be one of the most wondrous and necessary of treatments. The case of IVF falls squarely within these "what is health" and "what is disability" questions.

The draft guidance says that three attempts with fresh embryos and three with frozen offer the best chance of pregnancy. Nice also says - this is the nub of it - that treatment will be most effective and offer best value for money if limited to women under 40. Nice, you see, employs a deeply flawed methodology known as "economic analysis". Economic analysis compares the costs and consequences of alternative treatments for any given condition, and it is promoted as a rational, scientific means of containing costs. But in reality, it is little more than a spurious justification for imposing value judgements that are hidden from view. The very purpose of basing rationing decisions on the outcomes of economic evaluation is to provide an apparently objective alibi behind which intensely difficult political decisions - what, and how, to ration - can be hidden.

The chances of successful conception over 40 are indeed small, and the amounts of money that would need to be spent to make such attempts possible on the NHS may well be a "waste" of scarce resources. But be clear what Nice's guidelines mean; an issue that is fundamental to the critical questions of what we expect from the NHS, and what we mean by health, is being tackled not as the result of a national debate, not as the consequence of individual medical consultations, and not as part of a wider discussion of what we expect from the NHS.

Instead, it is being dealt with by sham concepts such as economic analysis. The IVF controversy is but one, albeit stark, example of how incremental NHS reform is bound to fail. Until we realise that no nationally determined, state-funded, state-implemented healthcare system can deal with such pressures, we will never cope.

stephenipollard@hotmail.com

The writer is a senior fellow at the Centre for the New Europe, a Brussels-based think tank.