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11.40 am
Dr. Peter Brand (Isle of Wight): This is a debate about whether the NHS is really a national health service. Today, we should be offering congratulations on the enormous advances that have been made in the treatment of infertility--a tremendous clinical and scientific success story. Instead, we are debating the failure of the NHS, because the story is one of failure to provide fair access to services.
We have heard interesting examples from both sides of the House, and I welcome the realisation by politicians that we need to start talking realistically about rationing. Such decisions cannot be left to doctors; we cannot pretend that they are clinical decisions. There are clinical decisions to be made, about eligibility criteria for starting courses of in vitro fertilisation and for the investigation and treatment of infertility in general. However, a host of other eligibility criteria have been produced, and they have nothing to do with clinical practice.
Some eligibility criteria are based on the financial cycle. In my health authority area, one could have two cycles a year, but no more than four. We can imagine the sort of family planning that went into ensuring that one managed four consecutive cycles without falling foul of the rules. In the context of clinical practice, that is nonsense.
It is wrong for a local or regional health authority, or even for an individual GP, to start making value judgments about whether a couple is stable enough to
deserve such treatment. People should not pretend that that is a clinical decision. Such decisions are emotive and political, and they should be made by people who are politically accountable, yet the way in which the NHS is now structured gives no local accountability whatever. People cannot sack their health authority. They can write letters--to their local Member of Parliament, for example--but, at the end of the day, the only responsibility is for the bottom line, for coming in on budget.
The only accountability is at parliamentary level. If we are to have a national health service, it is right for the Minister to set out clearly what people's entitlement and expectations from the service are likely to be. I am not prejudging the issue, because it is for the Government to set out clearly what they are prepared to fund and to take the political consequences if they get it wrong.
If the Government set out clear entitlements, we shall be able to integrate the service between the private sector and the NHS, and introduce a proper policy whereby GPs can prescribe and give the injections that make the egg ready for IVF treatment--we are talking, in the main, about IVF. There would be a planned service so that people would not have the awful embarrassment of having to chase around seeing multiple agencies, and sometimes being devious, as the only way of achieving what they desperately want.
Such an integrated service would also stop people bankrupting themselves. They would know where they were with fertility treatment. So often, people have two treatments on the NHS and are so sure that a third one would work that they see whether they can raise the money, and go into debt. Even if they are successful, that is an awful way to start a family.
The mark of a civilised society is not only how it treats ill health but how it promotes health. I am glad that we have a Minister responsible for the promotion of health and well-being. Personally, I believe that there is a role for the state in ensuring that people can have babies and a family if they wish. We could indeed create the supportive society to which everybody pays lip service. However, to achieve that, we need to will the resources.
The Government could be brave and say, "That form of treatment is not an NHS responsibility, but we might make a contribution for people who cannot afford to pay," which would be a sort of means test in reverse. I would not support that view. I think that everyone should be entitled. However, I also know that many people who undergo IVF treatment are keen to make a contribution, which makes their baby even more valued.
Dr. Ian Gibson (Norwich, North):
I congratulate the hon. Member for Meriden (Mrs. Spelman) on choosing the debate and on introducing it in a sensitive and erudite way. I should like to play a part in the debate by discussing fertility and the reasons for infertility, and what
The evolutionary drive to pass on one's genes to the next generation is a powerful force. The hon. Member for Meriden mentioned the social influences on that process, in terms of getting married, having children and living happily ever after. Sadly, the biological processes of the production of sperm and egg do not always allow that to happen.
The hon. Lady also mentioned that one third of fertility disorders are attributable to the male. In my experience, the vast majority of cases investigated involve both male and female factors. There is a tendency for the official figures to underestimate the extent of the problem, as many couples do not seek help because of embarrassment or lack of funds. Many are reluctant to seek assistance.
Infertility is often regarded as a nuisance illness, but, in fact, it is a major source of depressive illness and psycho-social morbidity in the United Kingdom. In that sense, it makes heavy demands on medical and social services.
What are the causes of male infertility? There may be a deficiency in sperm numbers, a reduction in sperm motility, the production of abnormal forms of sperm--involving the size of the head, for instance--blood vessel abnormality around the testes, obstruction of the sperm ducts, testes hidden in the abdominal cavity, or, of course, impotence.
Some of those are caused by genetic factors, some by physical and surgical events--infections, through mumps, for example--and some by environmental causes such as heat. You will know, Mr. Deputy Speaker, that many people in Scotland advocate the wearing of kilts to protect sensitive organs from the effects of heat--I am not declaring an interest in kilt wearing, incidentally. Radiation also has a major effect on sperm production.
Drugs, alcohol and tobacco are also well known to have effects on sperm production. There is also increasing evidence of adverse trends in several measures of male reproductive health--in testicular cancer, for example. There is also the increasing use of environmental chemical contaminants that mimic oestrogen hormone-like activity. Although the causal relationship is by no means proven yet, and diet and life style might be equally important, findings about the effects of hormone-like chemicals on wildlife make one think that the so-called endocrine disruptors may be important factors affecting sperm production.
Questions have been asked about semen quality as sperm counts fall; there is international agreement on that point--about 20 per cent. of our population have so-called low sperm counts. If they want further details, I recommend that hon. Members read a good document produced this year by the Parliamentary Office of Science and Technology on hormone-mimicking chemicals.
What of the treatments that are now available? The media have recently been awash with reports on the miracle drug Viagra, which is crudely called, in that all-American way, the "Pfizer-riser" and which is exciting males across America to the extent that 40,000 prescriptions are issued every day and it has almost become a recreational drug. It is given for what we in the business call erectile dysfunction. Whether it will come
to this country and how it does so remains to be seen. There are also surgical methods, but few studies have been made of microsurgical techniques to loosen duct abnormalities, and little has been happening on what should be an exciting front.
Other exciting treatments are becoming available, including intra-uterine insemination, which has its problems, as hon. Members have pointed out; in vitro fertilisation, which has changed our whole concept of male infertility; donor insemination; and intra- cytoplasmic injection, the ICSI method, which is relatively new. Human need has been so desperate that people have been prepared to accept the latter treatment before full scientific tests have been carried out. That is part of the problem. Many babies have been born by that method, whereby a single sperm is delicately and skilfully put into an egg cell and, although few people have the necessary skill to do that, the technique is being developed throughout this country. Men can now father children by that technique, and success rates are high at Bourn Hall clinic in Cambridgeshire and at the Hammersmith hospital under a distinguished member of another place.
Centres are licensed according to ethical compliance and not treatment efficiency, so couples might be squandering both resources and their chance of parenthood in having to seek treatment in the private sector for about £2,000 per session; only the most affluent in our society can afford to do that. However, ICSI treatment means that 35 per cent. of infertile males get a viable pregnancy in a single cycle, which is better than the IVF record at this stage. It is a remarkable development and a success story in male infertility. Problems may yet be encountered with ICSI, and further studies are being carried out, but the babies born so far by the technology have no higher incidence of any detectable abnormality than the general population of babies born after in vitro fertilisation or natural events.
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