Public views on our proposals to restrict access to ...test.bathandnortheastsomersetccg.nhs.uk/assets/... · restrict access to fertility, vasectomy and sterilisation services Full

Public views on our proposals to restrict access to fertility, vasectomy and sterilisation services Full consultation report

This report can be made available in a range of languages, large print, Braille, or on CD/tape. To request an alternative format, please email [email protected] or call 01225 831 800.

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Contents

1. Consultation summary…………………………………………………………………….........3 2. What the CCG is proposing to change……………………………………………………..…5 3. Why the CCG is making these proposals…………………………………………………….6 4. How the CCG consulted the public……………………………………………………….......6 5. Results – what the public told us……………………………………………………………....9 (i) Fertility treatment………………………………………......................................................11 (ii) Vasectomy and sterilisation services……………….......................................................23 6. Public ideas for other ways the CCG could save money…………………………………32 7. Conclusion …………………………………………………………………………………….33 Appendix 1: Frequently Asked Questions (FAQs) Appendix 2: Feedback results tables Appendix 3: Profile of respondents Appendix 4(i): Fertility Equality Impact Assessment (EIA) Appendix 4(ii): Vasectomy/sterilisation Equality Impact Assessment (EIA) Appendix 5: Feedback received by email/letter and CCG responses Appendix 6: Information shared by CREATE Fertility Appendix 7: Survey and face-to-face comments in full Appendix 8: PR and social media analysis

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1. Consultation summary This report summarises feedback shared by the public on our proposals to:

Restrict access to fertility treatment.

Stop funding male vasectomies and female sterilisations in all but exceptional circumstances.

The public consultation was open from 8 November to 27 December 2017 and then reopened for a further three weeks, until 31 January 2018. We extended the consultation in response to requests we received at our public meeting (on 8 January) to give more people the time and opportunity to share their views with us. The consultation period lasted 10 weeks in total. We engaged widely across B&NES, and in a variety of ways, to ensure that a range of groups were informed of the proposals and able to access and respond to the consultation. We asked people to share their views in person, via focus groups, street consultations, 1:1 discussions, and at a public meeting. Surveys on both proposals were available online and in paper form and shared via local services, such as GP surgeries and libraries, and on Twitter and Facebook. We also encouraged people to contact us with queries and feedback via email, telephone and in writing. In total, we had 1,109 responses to the consultation (on both proposals). We received 942 responses to the surveys and met with 138 people face-to-face. The remaining 29 interactions came via feedback sent directly to the CCG by email and social media. Thank you to everyone who shared their views with us and helped us to promote the consultation and engage with different groups of people across B&NES.

Results summary – what the public told us Proposal to restrict access to fertility treatment People shared a wide range of views both for and against the proposal (both in general and related to the specific criteria). Reasons included:

Couples tend to have families later, due to pressure to become financially stable and so that women have the opportunity to progress in their career.

Concerns that the proposal discriminates against women.

Concerns that people will try to start a family before they are ready to.

If women aged over 35 are less likely to conceive naturally, they are in greater need of the treatment.

70% of survey respondents disagreed with the suggestion to narrow the age range

that women can access fertility treatment from 23-40 to 23-35.

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By the time couples may begin trying and discover they are infertile (after a 2 year period), the female partner may be too old to access the service.

Reasons included:

The importance of people getting fit for pregnancy.

Equal/fair terms for men and women when accessing services.

The benefits of becoming parents at a younger age.

It should be about timescales of trying and not age. However, there was also a substantial level of disagreement from people who felt:

The proposal discriminates against people according to their age and weight.

The proposal introduces criteria based on factors which do not necessarily limit pregnancy or the health of a child.

All people should have the opportunity to become pregnant and that the groups mentioned are likely to need more support.

It is unfair that access to fertility treatment depends on where you live.

Concerns that the proposal goes against guidance on IVF from the National Institute for Health and Care Excellence (NICE) and requests for more clinical evidence for the suggested changes to the criteria.

Proposal to stop funding male vasectomies and female sterilisations A large proportion of people who responded to the consultation disagreed with the proposal. Reasons included concerns that:

Unplanned pregnancies would cost individuals, the NHS and the wider system much more than a vasectomy/sterilisation procedure.

The proposals would mean women have to take a greater burden of responsibility for contraception.

Male choice/options for contraception would be even more limited.

The proposal would affect those on low incomes.

50-60% of survey respondents agreed with the proposal to:

- Introduce a restriction on body mass index (BMI) for all female and male

partners.

- Introduce an age limit for male partners.

- Ask that couples try to conceive for at least two years before accessing

treatment.

74% of survey respondents were against stopping funding male vasectomies in all but exceptional circumstances.

67% of survey respondents were against stopping funding female sterilisations.

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Comments in favour of the proposal were more limited, but focused on the financial pressures the NHS is under, and the belief that the NHS should focus spending on treating ‘illness’.

Next steps A summary of the public’s feedback will be included in a report, with recommendations, which will be presented to the Clinical Commissioning Group (CCG) Board for a final decision to be made when they meet on Thursday 8 March 2018. This meeting will be in public and will take place from 10-11.30am at Somerdale Pavilion, Tiberius Road, Keynsham, BS31 2FF. Members of the public are welcome to attend the meeting and observe. People can submit questions in advance by emailing [email protected] or calling 01225 831 800. Details of the final decision will be published on our website and shared widely to ensure that everyone who took part in the consultation can find out what people said and how the CCG has responded.

2. What the CCG is proposing to change

(i) We are proposing to change the criteria for accessing fertility treatment to the following:

B&NES CCG would continue to fund one full cycle of In vitro fertilisation (IVF)/Intracytoplasmic sperm injection (ICSI) and one frozen cycle for those who meet the eligibility criteria. If the proposed changes are carried out, a saving of £100,000 - £160,000 is expected.

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It is expected these changes would affect approximately 50% of patients accessing fertility services. That would be approximately 30 couples per year. It is estimated potential savings would be £100,000-£160,000.

(ii) We are proposing to stop funding for both male vasectomies and female sterilisations in all but exceptional circumstances*.

*Patients with exceptional circumstances would still be able to apply for funding through a route called an individual funding request. If the proposed changes are carried out, a saving of up to £40,000 is expected.

3. Why the CCG is making these proposals NHS Bath & North East Somerset Clinical Commissioning Group (BaNES CCG) faces a significant financial challenge. The population of B&NES is growing and changing and this is having an unprecedented impact on the local NHS budget, which is now significantly stretched. In order to comply with our duty to live within our means (not get into debt) and to continue providing services to patients in urgent need, we have had to think about where we might make changes to services to save money. Early in 2017, we stopped providing gluten-free foods on prescription for people with coeliac disease, and over-the-counter medicines for short-term ailments. We are also part of a consultation across the South West that is looking at who should be eligible for non-urgent patient transport. The changes we have made so far have helped us strengthen our financial position, but we are still facing a possible deficit without taking further action. This has led us to consider restricting other non-urgent services. Following a Joint Commissioning Committee (JCC) meeting held on 28 September 2017, it was decided that a public consultation be launched on proposals to restrict access to fertility treatment and stop funding male vasectomies and female sterilisations in all but exceptional circumstances.

4. How the CCG consulted the public How we promoted the consultation The public relations and social media campaign that promoted our consultation on proposals to restrict access to fertility, vasectomy and sterilisation services ran in parallel with the consultation itself, from 8 November 2017 to 27 December 2017, and then again from 11 January 2018 to 31 January 2018.

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We worked with local media to publicise the launch of our consultation and received coverage on BBC Points West and the ITV Evening News, and four BBC and local radio interviews on BBC Wiltshire and Bristol, Heart and Breeze FM. We informed these media channels when our consultation reopened and a story was published online in the Bath Chronicle. The combined regional reach of the radio interviews and television coverage over these two days was substantial; certainly the greatest generated by a CCG announcement in recent years. During all interviews, Dr Ruth Grabham (GP and Medical Director at the CCG) relayed the key message that viewers/listeners should take the opportunity to share their thoughts on the proposals and help inform the decision-making by completing the surveys online or requesting paper copies by contacting the CCG directly. We shared information about the consultation on our website and ran a social media campaign on Twitter and Facebook, with up to eight posts per week on each platform until the closure of the consultation. B&NES Council, Healthwatch, and other local services and third sector organisations supported this promotion, and we designed social media posts with particular audiences in mind, identifying organisations and charities that represent those who might be most affected by the proposals, minority groups, and those who are seldom heard or vulnerable. While this approach did not always result in any sharing of our messages, we had success with a few groups, including The Diversity Trust and Men’s Health Forum. We published an article in B&NES Council ‘Together’ magazine at the start of December, asking people to get involved with the consultation – this magazine is sent to every household in B&NES. We also created posters to inform people of the consultation and how they could share their views, which were displayed in libraries, one stop shops and GP surgeries. Overall, our public relations and social media campaign resulted in considerable media coverage – online, in print, on radio and television, as well as large social media audiences who engaged with our content. Although it is hard to claim total causality, this activity has run in parallel with increases in the number of people completing our surveys, as well as an increase in the numbers of comments received on social media posts, emails received about the consultation and engagement process, and also in 19 people attending our public meeting on 8 January 2018. How we engaged with people

We engaged widely across B&NES, and in a variety of ways, to ensure that a range of groups were informed of the proposals and able to access and respond to the consultation. We asked people to share their views:

1. In person - Both 1:1 and in small groups during our street consultations in central Bath,

Twerton Park, Keynsham and Midsomer Norton.

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- In focus groups we arranged with specific/community groups and our patient and public involvement group, Your Health, Your Voice.

- At our public meeting in early January, when we invited the public, NHS staff, and anyone who got in touch with us individually about the proposals, to come together for a discussion.

2. By filling in our surveys

Individual surveys were created for both proposals and made available online and in paper form.

The online surveys were hosted on our website, promoted on social media, and in newsletters – both our own and those of our partners and stakeholders, such as Healthwatch.

Paper and electronic copies of the surveys were shared with patients via GP practices across B&NES.

Surveys were shared in One Stop Shops and libraries in Bath, Keynsham, Midsomer Norton and Paulton, and on the mobile library which visits different areas of B&NES.

3. In writing/via email/on the telephone

We encouraged people to email/write to/phone us and shared our contact details widely – in the surveys, on posters and on our website. We talked through the survey with anyone who wished to share their views, but could not access the paper or online versions. Specific groups and communities we engaged with Before the consultation opened, we produced Equality Impact Assessments (EIAs) to identify who would be likely to be affected by the proposals if they went ahead. Please see Appendices 4(i) and 4(ii) for the full EIAs and breakdown of these groups. To ensure that we heard from people likely to be affected by the proposals, as well as people who are seldom heard and socially vulnerable, we:

1. Met with organisations such as Bath Fertility Centre (the UK’s biggest fertility campaign group) and our local Sexual Health Board, and spoke with the Family Planning Association.

2. Set up discussions and focus groups via organisations working with specific groups and communities, including: - 1:1 discussions with people who are homeless (via Julian House). - Meeting with a community group of young women in Foxhill (via the Southside

Family Project). - 1:1 discussions with people getting advice at the Housing Options drop-in at The

Hollies in Midsomer Norton. - A focus group with sixth formers at Ralph Allen School. - A focus group with people who have learning disabilities and their support

workers (via Dimensions).

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3. Asked partner services and third sector organisations who represent specific groups to share the surveys with those they work with and support. St Mungo’s, the Avon and Wiltshire Mental Health Partnership NHS Trust (AWP), the Carers’ Centre, Virgin Care, Healthwatch, the Royal United Hospital (RUH) and B&NES Council helped us to promote the consultation both on- and offline. They also helped us to reach out to wider professionals who work with parents, such as head teachers of infant, primary and junior schools. We also used the extended consultation period to reach out to any groups, organisations or areas who had less representation in the consultation responses so far, including people living in rural/remote areas.

4. Created a consultation toolkit and session plan and shared this with professionals and members of our patient and public involvement group to engage with specific groups on our behalf.

5. Made efforts to proactively engage male groups in the consultation (as responses to our surveys were mostly from women), by holding pre-match discussions with the public at Twerton Park football stadium, approaching men during our street consultations, and tagging organisations such as the Men’s Health Forum and The Diversity Trust in our social media posts.

5. Results – what the public told us

In total, we had 1109 responses to the consultation (on both proposals):

Method Number of responses

Face-to-face conversations 138

Completed surveys 942

Email/letter feedback and questions 26

Freedom of information (FOI) requests 3

Total 1109

Here is a breakdown of the number of survey responses we received for both proposals:

Online survey response

Paper survey response

Total response

Proposal to restrict access to fertility treatment

484 37 521

Proposal to stop funding vasectomies and sterilisations in all but exceptional circumstances

393 28 421

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Here is a breakdown of the number of people we engaged with face-to-face for both proposals: Method Total Engaged

Keynsham street consultation 15

Bath street consultation 29

Midsomer Norton street consultation 24

Twerton Park pre-match consultation 7

Focus group with Southside Family Project community group 7

1:1 discussions with people who are homeless 3

Ralph Allen School focus group 9

B&NES Sexual Health Board meeting 8

Your Health, Your Voice (patient and public involvement group) meeting 8

Public meeting at St Martins Hospital 19

Focus group with people with learning disabilities/support workers 9 Total Respondents 138

Please see Appendix 3 for information about who responded to our consultation (broken down by age, gender, ethnic group, location etc.). 26 people shared their views with us via email/letter. Please see Appendix 5 for all feedback received by email/letter and CCG responses.

People also shared their views on the proposals via social media. Posts on both our Twitter and Facebook accounts received comments from individuals and organisations. The overwhelming majority were negative in tone (one comment was received from a fertility treatment provider about how the CCG could reduce the cost it pays for services) and were similar to themes that have emerged in the survey responses:

Fertility proposals are discriminatory to women and couples who want to wait to start a family when they are stable in career and housing.

Anticipated savings of both proposals are meagre.

Proposals to stop funding sterilisations and vasectomies could lead to unintended and costly consequences.

Proposal to stop funding vasectomies significantly limits the opportunity for men to contribute to family planning.

For the first two weeks of the consultation, the CCG website had a higher-than-average hit rate of over 1000 hits (compared with an average 700 hits per week), indicating the possible effect of the media exposure. By the end of the consultation period, our social media campaign reached just over 30,000 individual accounts across all three platforms. This equates to 16 per cent of the B&NES population. It should be noted, however, that these accounts do not all represent individuals – or individuals living in B&NES. Towards the end of the campaign, we paid for a ‘boosted post’ on Facebook, which was shared directly with adults in B&NES, at a cost of £40 (to the CCG). This post alone reached over 4,500 individuals’ accounts, and generated 80 ‘reactions’ from those individuals, including comments, shares and likes.

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(i) Proposal to restrict access to fertility treatment We had 673 responses to the consultation on our proposal to restrict access to fertility treatment (noting that 14% of responses to the survey came from people who live outside of B&NES). Response by question: Q. Do you understand why we are proposing to introduce these restrictions? 90% of survey respondents (470 of 519 who answered the question) said they do understand why we are proposing to introduce these restrictions.

Q. To what extent do you agree or disagree with our proposal to restrict access to fertility treatment based on the following criteria?

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Nearly 71%* of survey respondents (365 of 520 people who answered the question) disagreed with the proposal to change the age requirement of the female partner. This was the most contentious element of the proposed criteria.

58% of survey respondents (304 of 521) agreed that the female partner should have a body mass index (BMI) of 19-30 for at least six months prior to treatment.

Nearly 60% of survey respondents (308 of 517) agreed that the male partner’s upper age limit should be reduced to 55.

54% of survey respondents (281 out of 521) agreed that the male partner having a body mass index (BMI) of 30 or less.

55% of respondents (287 out of 521) agreed that couples must have tried to conceive for at least 2 years.

We also asked people this question during our focus groups, street consultations and 1:1 discussions. Their views were as follows: Face-to-face engagement results

Strongly Agree

Somewhat Agree

Neither agree nor disagree

Somewhat Disagree

Strongly Disagree

Total response

Female partner is aged

23-35 years

7 12%

13 22%

7 12%

8 14%

24 40%

59

Female partner has a BMI of 19-30 for at least 6

months prior to treatment

22 38%

14 24%

4 7%

1 2%

17 30%

58

Male partner is aged 55 or

younger

16 35%

12 26%

5 11%

5 11%

8 17%

46

Male partner has a BMI of

30 or less

21 44%

14 29%

5 10%

1 2%

7 15%

48

Couple have tried to

conceive for at least 2 years

20 36%

11 20%

4 7%

14 25%

7 13%

56

(Please note: of the 138 people we spoke with face-to-face, not everyone shared the extent to which they agree or disagree with the proposal). Both the survey and face-to-face responses show that a greater number of people are against changing the age criteria for female partners.

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The proposals that the male partner be aged 55 or younger, that couples must have tried to conceive for at least two years, and that women must have a BMI of 19-30, received similar levels of agreement from people who shared their views face-to-face. The exception was the proposal to introduce a BMI limit for men, which 73% of those we met agreed with (compared to 54% of survey respondents). Proposed change #1: female partner is aged 23-35 years Reasons people disagreed with this part of the proposal included:

Couples tend to have families later, due to pressure to become financially stable and so that women have the opportunity to progress in their career.

Concerns that the proposal discriminates against women.

Concerns that people will try to start a family before they are ready to.

If women aged over 35 are less likely to conceive naturally, they are in greater need of the treatment.

By the time couples may begin trying and discover they are infertile, the female partner may be too old to access the service. This age restriction, together with the proposal that couples must try for two years, substantially narrows the opportunity for people to gain access to NHS-funded treatment.

Some people said they would support an increase in the lower age limit.

“The drop in the mother's maximum age is cruel. Often, this is a last resort, and

they will, by definition, be older women. Don't make the pain of infertility worse

for people already suffering.”

“…Fertility declines after 35 which means you are cutting off access to a service

when it might be needed most.”

“Change the age parameters to 25-42 for women. Times have changed,

economically and socially. Couples are getting married later in life…Many

couples face financial challenges, struggling to get employment and housing, so

many couple delay parenthood wanting to prepare responsibly.”

“This change in the age undermines women's rights and access to employment

and a career.”

“IVF success rates can still be very good over 35 - I was given a 60%

chance of success at age 36. Sometimes circumstances dictate that

you don’t try for a baby until your 30s, therefore you could well be

over 35 once you have tried to conceive naturally for a few years and

gone through numerous tests.”

“I think the combination of female age limit and two years trying to

conceive is too restrictive…”

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Proposed change #2: female partner has a BMI of 19-30 for at least 6 months prior to treatment. This applies to all women. Reasons for agreeing with this part of the proposal, focused on the following:

However, a number of people raised concerns about using BMI as a measurement:

Some people asked if exceptional circumstances would be in place for those who could not help being overweight, and a number of respondents felt that women with polycystic ovaries should be excluded:

Some people were concerned that this would be discriminatory, as being overweight is often linked to low income.

“I think restricting based on BMI is sensible as it will lead to healthier pregnancies.”

“It's fair enough to restrict access where there is something that people can change

about themselves e.g. BMI”

“Some of the criteria I would have expected to be in place anyway, i.e. being a healthy

weight.”

“Agree people should not be grossly overweight, however BMI doesn’t necessarily

account for muscle weight??”

“BMI has limitations and so should not be used so stringently”

“BMI is a deeply flawed system that fails to take a lot into account, including genetics.

There is lots of research that people with an "overweight" BMI are healthier in multiple

ways than people with "normal" scores, including the ability to carry children.”

“Disagree with proposed changes to restrict women dealing with polycystic ovaries.

Typically they struggle to lose weight, meaning reaching a BMI of 19-30 would be

difficult.”

“Polycystic ovaries can cause weight gain and it's a medical condition. Other

conditions are treated (even those that are 'lifestyle' related) so why are women

being penalised?”

“Women with higher weight may have other health issues affecting it that also

increase their risk of infertility.”

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Proposed change #3: the male partner (in the case of heterosexual couples) is aged 55 or younger The majority of respondents agreed with this part of the proposal. Some people felt that the age limit could be lowered even further and should be more in line with the age limit for females: However, some people questioned the need for a male age limit: Proposed change #4: the male partner (in the case of heterosexual couples) has a BMI of 30 or less A number of respondents supported the BMI restriction for men for health reasons, and because they felt it should be the same as the criteria for women. However, some people raised concerns that there is not sufficient evidence for this part of the proposal and, as for the criterion for women, felt BMI is not an appropriate way to measure obesity:

“What is wrong with men over 55?”

“55 is hardly uncommon for a man to have a child.”

“Why the disparity between ages of female and male partners? 55 [is] too old to

father first child.”

“….Meanwhile, her male partner can be up to 55 years old. I understand biology but

that discrepancy is huge and unfairly disadvantages females trying to conceive. I

suggest females kept to 40 and men 50, should you need to make any adjustments.”

“Male age should be the same as female. This is a difficult decision but decisions

should be made on factors that increase success.””.

“The male partner should have the same age and BMI restrictions as their female

partner”

“Both female and males need to be at the correct BMI in order to get most success.”

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Proposed change #5: duration of infertility of at least 2 years Some people felt that two years was too long, especially when considering the proposal to narrow the age criteria to 23-35. Some respondents were concerned that, by the time couples discovered infertility issues, they may no longer be eligible to access fertility treatment. Other people felt that 1 year was sufficient for couples to discover fertility issues.

Those who supported this part of the proposal, supported the proposal as a whole. Respondents who specifically gave support for a two year period trying to conceive, suggested conditions around age criteria and felt it depends if a couple are seeking help for the first time.

“I do understand the restrictions on women as they have to go through the

pregnancy but do not understand why there is now a male weight limit other than

purely to make cuts”

“The male age and BMI restrictions are also discriminatory without sufficient clinical

evidence to back them up.”

“The adult BMI does not take into account age, gender or muscle mass.”

“Delaying referral for 2 years is a long time. 1 year is reasonable. Even if referred

after 2 years, you may not conceive for years once treatment has begun. Also

delaying may not be optimal for the couple who may be on the older spectrum”

“The combination of 2 years trying to conceive and then an age limit of 35 for the

female partner means that couples who may have fertility issues must know this by

the time the female partner is 33 years old.”

“I would support the 2 year duration of infertility restriction if the upper age limit was

kept at 40 as this is a more realistic time-frame for most women in the modern world”

“If it's when a couple first presents at their doctor than 1 year would seem a sensible

maximum as that gives time to try other treatments. If it's from when a couple start

trying then 2 years would seem reasonable as this would mean 1 year after a couple

first seek help from their doctor as a couple should wait one year before seeking this

help if under 35.”

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Comments on the proposal as a whole: Approximately 13% of the survey comments were in agreement with the entire proposal. Reasons for this included infertility not being an illness, and the need to consider the financial position of the NHS. A greater proportion of the survey comments disagreed with parts (or all) of the proposal. Reasons included:

It is unfair that access to fertility treatment depends on where you live;

The proposal is discriminatory;

Concerns that the proposal goes against guidance on IVF from the National Institute for Health and Care Excellence (NICE).

The NHS should be properly funded and some urged a stronger pushback to central government.

“In straitened times, I believe that we should be restricting access to certain

services, including fertility services. I am saying this as someone who has

struggled with fertility.”

“Infertility is neither a terminal nor life-threatening condition and given that cuts

need to be made, IVF treatment is an obvious candidate.”

“There is no absolute right to have children and at the same time, there are many

children waiting to be adopted.”

is

“I understand that the CCG has a finite resource which it has to manage as

equitably as possible…I don't understand the point of having National Guidelines

if each CCG then makes its own arbitrary decision…”

“I think it is a terrible idea, I am very against it. I am very angry about it. Infertility

is an illness. NHS should be for EVERYONE including FERTILITY FAIRNESS, this

should not be a postcode lottery.”

“You should be implementing the recommendations from NICE. That is 3 funding

cycles per couple, anything less is a failure to those patients and frankly

immoral.”

“The Clinical Commission needs to put pressure on the government to continue

to provide funding, so that these services are not withdrawn.”

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Other themes: Mental health A number of people shared concerns about the potential impact on people’s mental health of restricting access to fertility treatment: Case-by-case Some respondents said they would rather the decision (to provide NHS-funded treatment) be made on a case-by-case basis, taking into account people’s individual circumstances: Other restrictions A small number of respondents asked whether the CCG could look to restrict access to fertility services based on other lifestyle factors. A couple of respondents also referenced adoption – either stating that access to fertility services should be the same as for adoption services, or stating that families should look into adoption rather than fertility treatment.

“…from a mental health perspective, 2 years is a long time to expect those suffering with infertility to wait without treatment, and should be considered carefully. Will additional psychological well-being support be provided..?” “I think it…will result in other costs to the NHS as such restriction will undoubtedly lead to an increase in depression and mental health issues for those concerned. Suffering from infertility problems can be extremely isolating”

“I believe decisions should be made on a case by case basis. Strict criteria does not allow for individual discretion and exceptions to the norm.”

“What about restricting access to people who smoke? Also, what about people who already have children?” “Criteria should be similar for that for adoption.”

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Look at others areas first Other respondents suggested that the CCG focus on other areas:

Some people were unclear on whether there was a change to the number of IVF cycles [Please note: this did not form part of the proposal]. A couple of respondents stated that they did not believe the cuts would save sufficient money for the CCG. Q. Would you be affected by these changes? 72% (374 of 516) of those who filled in the survey said they would not be affected by the proposed changes:

During our face-to-face engagement, we spoke with groups and individuals who could potentially be affected by the proposed changes, including: young women and men who do not yet have children, women who have polycystic ovaries, a group of young people aged 16-18, and men aged 55+. Q. If you were unable to access NHS-funded treatment would you be able to pay for the treatment yourself?

49% (181 of 368) of survey respondents would not be able to pay for treatment themselves.

32% (118 of 368) could pay for the treatment either straightaway or eventually.

19% (69 of 368) were unsure.

“I would guess that there were other areas that I would look to make savings before fertility treatment.” “There are many other NHS funded operations that should be review before this in terms of less spend i.e. obesity, drug addiction.”

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Of those who said they would not be able to pay for treatment, more people disagreed with the proposal to amend the female age criteria.

Other (formal) responses The CCG received responses from a number of organisations against the proposals, including Fertility Fairness, the B&NES Labour Group, Men’s Health Forum, as well as questions from local councillors. Fertility Fairness Fertility Fairness (formerly the National Infertility Awareness Campaign) is an organisation which has campaigned for people to have comprehensive and equal access to NHS infertility investigations and treatment. Berkeley Greenwood, Secretariat, completed the CCG’s survey on behalf of the organisation. Fertility Fairness is strongly against the proposal and feels it amounts to a ‘decommissioning of specialist fertility services’. In their response, they:

Stated that infertility is a recognised disease.

Shared their view that CCGs should adhere to NICE guidelines and eliminate the postcode lottery.

Listed their concerns on equality for accessing services.

Referenced the long-term costs associated with decommissioning fertility services, costs for IFR, and neighbouring (BNSSG) consultations.

B&NES Labour Group B&NES Labour Group emailed the CCG to share their concerns on both the fertility and vasectomies/sterilisations proposals. They listed their concerns as follows:

Infertility is a medical condition which should be funded according to NICE guidance.

There is no clinical evidence to support limiting the age at which women can access IVF treatment.

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The age of first time mothers is rising.

Infertility can be both financially and emotionally devastating.

The postcode lottery for fertility treatment is unfair. Men’s Health Forum The Men’s Health Forum tweeted the following: “Men’s Health Forum condemns proposals to cut reproductive health services for men and women by @nhsbanesccg – particularly proposal to cut access to IVF for couples where the man has a BMI>30.” They followed this with a news article containing comment from their Chief Executive Martin Tod: “We’re strongly opposed to these proposals. It’s a false economy to cut the options available to men to support their family planning and reproductive health. When weight management services in the Bath & North East Somerset areas are working so poorly for men, we’re particularly strongly opposed to the proposal to require men to lose weight before couples are supported for IVF. Even though men are the majority of people who are overweight or obese, the way local weight management services are designed means that men are less than a quarter of those using them. It's also unacceptable that the full range of family planning options will only become available to families who are better off and can afford to go privately. The problems of unwanted pregnancy and the sadness of involuntary childlessness don’t just affect people with money: everyone needs to have access to the choices they need - not just the young, slim or rich.” They also submitted a response to the survey: No analysis has been done of how these policies interact. The net effect of these combined policies could be to reduce the chance of IVF succeeding – and impair the cost effectiveness of CCG spending. The BMI-related policies would have the effect of effectively delaying treatment for couples – which the consultation paper itself acknowledges is likely to lead to reductions in fertility for both partners. No analysis has been presented to demonstrate that, for example, the improvement in a man’s fertility as a result of weight loss would necessarily compensate for the loss in a woman’s fertility over the period of that weight loss – or to demonstrate what the impact might be on IVF succeeding. There is a serious risk of unintended consequences – with the combined effect of these proposed policies reducing the chance of IVF being successful – and reducing the cost effectiveness of the CCG’s spending. The paper is also incomplete. Involuntary childlessness has been found to put significant pressure on relationships and on couples’ long-term wellbeing. The paper makes no analysis of this impact on couples’ relationships, mental health or wellbeing following from these proposed policies – all of which are likely to be negatively affected as a result of the proposed policies – and all of which may incur extra costs to the CCG and to wider society in the longer-term. The BMI limit outlined on the website is arbitrary – and seems purely designed to cut cost

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It is ironic that B&NES CCG is putting forward proposals that would mean that more than 70% of Bath Rugby Club’s forwards would not be able to access IVF with their partners should they need to. BMI is a blunt instrument and does not automatically do proper justice to men’s health, weight or fertility. The proposals will also have a very wide-ranging impact. The Health Survey for England estimated that in 2015 around 24% of men in the South West had a BMI of over 30. Critically, no evidence has been presented that this measure would improve the chance of IVF succeeding or the cost effectiveness of CCG spending – only that it affects non-IVF fertility. Other exclusion criteria and methods have also not been evaluated – for example measuring the quality of sperm and the likelihood of success before proceeding with IVF. Setting a weight management criterion for men when local weight management services are failing to reach and engage men – is unfair and unreasonable. Even though men are consistently more likely to be overweight and obese than women across the UK at every age, the way local services are designed in Bath & North East Somerset means that local men are less than a quarter of those using them. In a 2017 FOI request by the Men's Health Forum, Bath & North East Somerset Council reported that, in 2016/17, approximately 16% of 632 participants in public health sponsored weight management programmes with Slimming World and Weight Watchers were men. In 2015/16, 25% of the 130 people referred to their GP Counterweight programme were men - with a similar proportion reported for 2016/17. For as long as weight management services in the CCG areas are failing to engage men, it is unreasonable to use BMI as a criteria to exclude men from services. Finally, the core thinking behind the proposals – namely restricting access to IVF people who are more likely to have fertility problems – is illogical and unethical. The purpose of IVF is to achieve pregnancy and help those who are infertile. The new criteria seem to be designed to arbitrarily exclude some couples with infertility that IVF is intended to remedy, rather than to exclude on evidence that treatment could not be effective. They also sent the CCG a formal response by email (please see Appendix 5). Alternative providers The CCG was contacted via the survey and Twitter by CREATE Fertility, claiming they could offered CCG a ‘lower cost IVF, delivering huge savings without the need to restrict’. The CCG emailed CREATE and had a telephone call in December 2017 to find out more. Please see Appendix 6 – Information from CREATE Fertility – for further information. Petition An online petition was set up in response to the proposal: Stop cuts to IVF services in BaNES. The petition has received 25 signatures to date.

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(ii) Proposal to stop funding male vasectomies and female sterilisations in all but exceptional circumstances We had 577 responses to the consultation on our proposal to stop funding male vasectomies and female sterilisations in all but exceptional circumstances (noting that 14% of responses to the survey came from people who live outside of B&NES). Response by question: Q. Do you understand why we are proposing to introduce these restrictions? 94% of survey respondents (394 out of 417 who answered the question) said they do understand why we are proposing to introduce these restrictions.

Q. To what extent do you agree or disagree with our proposal to restrict male vasectomies in all but exceptional circumstances? 74% of survey respondents (309 of 419) disagreed with the proposal.

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We also asked people this question during our focus groups, street consultations and 1:1 discussions. Their views were as follows: Face-to-face engagement results

To what extent people agree/disagree with stopping funding:

Strongly agree

Somewhat agree

Neither agree nor disagree

Somewhat disagree

Strongly disagree

Total Responses

Male vasectomies in all but exceptional circumstances

18 20%

20 23%

12 14%

9 10%

29 33%

88

(Please note: 88 of the 138 people we engaged with face-to-face shared the extent to which they agree or disagree with the proposal). The number of people who agreed with the proposal was the same as those who disagreed. Proportionately, more people who we engaged with face-to-face agreed with the proposal, compared with those who responded to the survey. Q. To what extent do you agree or disagree with our proposal to restrict female sterilisations in all but exceptional circumstances? 67% of survey respondents (276 of 409) disagreed with the proposal to restrict female sterilisations in all but exceptional circumstances.

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We also asked people this question during our focus groups, street consultations and 1:1 discussions. Their views were as follows: Face-to-face engagement results

To what extent people agree/disagree with stopping funding:

Strongly Agree

Somewhat Agree

Neither agree nor disagree

Somewhat Disagree

Strongly Disagree

Total

Female sterilisations in all but exceptional circumstances

11 16%

13 19%

7 10%

6 9%

30 48%

67

(Please note: 67 of the 138 people we engaged with face-to-face shared the extent to which they agree or disagree with the proposal). Similar to the survey response, a greater proportion of people disagreed with the proposal. Comments on the proposal as a whole: A small proportion of respondents agreed with the proposal. Reasons included:

There being other contraceptive options freely available;

Sterilisation is a lifestyle choice;

The feeling that it’s necessary in the current financial climate.

“I think this is possibly a good way to save money, however I do hope that men and women are still given the support and information they need of they are considering this procedure and need to be aware of how much it would cost them to go private.” “I think this is one way to ease the financial situation in the health service. We can then concentrate more on prevention and treating sick people!” “As a retired GP, (I used to work in North Somerset), I think that your proposals are fine providing you provide an easily accessible, cheap, non-profit making vasectomy and female sterilization service that works seamlessly with the NHS. Private consultants can charge very high fees for vasectomies, yet I have seen it done for much cheaper fees by interested GPs.” “Now that birth control is readily available with choice of method, I do not think vasectomies and sterilisations are really necessary.”

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However, a large number of survey respondents were against the proposal, and, in particular, the idea of any services being cut in the NHS. Reasons people disagreed with the proposal (themes): Unintended consequences (financial and social impact) The largest group of survey respondents were concerned with the potential financial and social impact of the proposal. They shared concerns that:

Unwanted pregnancies (if aborted or carried to full-term) are more expensive than a sterilisation procedure.

These pregnancies can have a negative effect on people’s mental health.

If children result from these pregnancies, they may be unwanted or have difficulties (as a result perhaps of difficult/older pregnancies) and cost the health and care, housing and education systems more in the long-term.

“I strongly believe these services are a right and should be free on the NHS. You argue that you need to "restrict these services is that the population of (B&NES) is growing". The whole point of these practices is to limit population growth” “Maintain the current free service and put pressure on central government to provide funding.” Countries such as France and Germany spend twice what the UK spends on health services. Concern that the health service is being destroyed [shared in a meeting].

“I strongly disagree with getting rid of these services. I think sterilisation and vasectomy are a vital form of contraception for some people and by removing this you are potentially allowing children to enter the world who are not wanted or cannot be supported financially or emotionally,” creating more problems within the welfare system.” “You talk about sustainability and living within means, while simultaneously removing a set of relatively inexpensive procedures that help people to do exactly that by preventing accidental pregnancies.” “It is far cheaper to fund vasectomy and sterilisations than it is for society to fund to support children that aren't wanted. I think we have a moral duty to allow people to undergo these procedures.” Cost implication of health risks, including impact on mental health, as a result of unwanted pregnancies/miscarriages/abortions [will cost the NHS more].

“Access to reproductive health services is a cornerstone of preventative medicine of which we hear so much.”

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Saving would be too small A few people felt that the saving would be too small: Discriminates against women Some people raised concerns that removing the option for men to have vasectomies for free, would mean the pressure of birth control falls back onto women (as there would be no other long term alternative for men). There were also concerns that long-term contraceptives (e.g. pill or LARC, such as the injection or IUDs) may not be suitable for certain women, due to side effects from hormones etc.

“Preventing people controlling their fertility results in very bad long term outcomes for very small savings” “I feel deeply uncomfortable about the restriction of male vasectomies. I feel that that the potential small financial gain does not offset the potentially detrimental effects of limiting a man's ability to access the only form of long acting contraception available to a man.” “Drop in the ocean in terms of money that will be saved.”

“It is especially important to retain vasectomy services as men have very limited choice of family planning services, and by cutting this service, puts the burden back onto women. This would be a huge setback in gender relations.” “Your proposal places an unacceptable and unfair burden on women, as they are the ones most affected by an unplanned pregnancy… pregnant woman would have to have an NHS abortion and face the emotional and physical risks inherent in that.” “Hormonal contraception is not appropriate for all women with physical and mental health implications” “I think vasectomies are very good value for money, and it is only fair that men should be enabled to do take responsibility for contraception. Not all women want to have other forms of contraception.”

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Discriminates against men Some respondents also raised concerns that stopping funding the only option for long-term contraception for men would take away their control over birth control: Discriminates against low income households People were concerned that this proposal would particularly affect those on low incomes, who would not be able to afford the procedure privately or additional children:

“GP said that we may assume it's all older men who have completed their family who want a vasectomy, but there are also young men (e.g. 28 year old she has seen) who just can't cope with more children and their partners won't/can't use contraception.” “I feel deeply uncomfortable about the restriction of male vasectomies. I feel that that the potential small financial gain does not offset the potentially detrimental effects of limiting a man's ability to access the only form of long acting contraception available to a man; with potential financial burden and psychological distress accrued from unwanted pregnancies/termination of.” “Someone said this is the only permanent choice for men, therefore it removes their choice.”

“One man shared he had a vasectomy on the NHS and might have put it off if he knew he had to pay for it. He said; “That doesn't seem fair on the wife to have to be responsible for contraception."

“Some families struggle with contraception and a sure solution should be provided where they can’t afford more children.” “I think it is a mistake to treat this sort of treatment as though it is some sort of lifestyle choice. Fine if people are well off and can afford to pay for this treatment, but what about women in difficult relationships who can't afford to have any more children and can't afford to pay?” “Restricting access is discriminatory affecting the poorest in society.” “I suppose I think that free sterilisations might very well reduce the costs/strain on the maternity system, and that charging penalises the poorest families most (those most likely to financially suffer if unexpected kids show up).” “The patients that need it the most are the poorer residents who will not pay privately for this.” If people can afford it, ok, but if you can't, you can't. Depends on circumstances…”

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Look elsewhere A significant number of respondents recommended that the CCG should look elsewhere to make savings in the system: Suggestions for exceptional circumstances During the consultation, we also asked people what they would consider to be ‘exceptional circumstances’ in which people should be funded to have the procedure for free. Many people said they thought everyone should be eligible for the services and there should be no need for exceptional circumstances. Others suggested the following should be considered as exceptional circumstances: Procedure Exceptions

Vasectomy Mental capacity Drug user Desire to restrict fertility People who have a medical reason why they cannot have any more children Difficulties with female contraception Significant poverty and multiple children Learning difficulties Man has more than two children Age Illness Physical disability Assess individually

Female Sterilisation

Mental capacity Drug user Illness Pregnancy would be life threatening Assess individually Multiple children Social issues with existing children Poverty Partner unable to have a vasectomy and LARC was unacceptable

“We should be looking to renegotiate with the provider, not make cuts.” “I would rather see people fighting for more money for the NHS - we can afford it if we want to.” “I do not support this proposal at all. Given the CCG is looking to restrict services, I think should be looking at restricting procedures for smokers, alcoholics and the morbidly obese - all self-inflicted and with significant cost to the NHS.”

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Some respondents agreed with the proposal in part, or suggested introducing a criteria that people need to meet in order to access the service. A number of these suggestions included means testing. Q. Would you be affected by these changes? 70% of survey respondents (283 out of 413) said they would not be affected by these changes.

However:

Amongst respondents who said they would be directly affected by the proposals,

90% were against changes to vasectomy and 78% against changes to female

sterilisation services.

A number of people said they would be impacted if the costs to meet unplanned pregnancies and beyond (as a result of these restrictions going ahead) meant that the B&NES NHS health economy deteriorated further.

“Introduce tighter eligibility e.g. physical/mental health risks of not having it done or means test it.” “I strongly disagree with a blanket ban, but would support tightening of criteria to save some funds. After all, costs of increased pregnancies/ births/child care (poss with disabilities) would be a greater cost than the initial sterilization! Certainly reversals should not be available on NHS.” “One person suggested that people should be asked to pay half (e.g. £250) and the NHS pays the other half” “Vasectomy and female sterilisation shouldn't be considered together as they're such different procedures involving cost disparity and different levels of invasiveness to the patient. Permanent contraception in the form of vasectomies should always be an option since they're (relatively) so cheap, so un-invasive, so reliable and are also the only proper method available to men.”

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A number of people shared that their family members were planning to undergo a procedure.

Others responded that it would be a choice in the future for them. During our face-to-face engagement, we met with several individuals and groups who would potentially be affected by the proposed changes, including: young mothers who have several children and men aged 40-50+. Q. If you were unable to access NHS-funded treatment for vasectomies or sterilisation, would you be able to pay for the treatment yourself? 36% of survey respondents (100 of 275) would not be able to pay for a sterilisation procedure. 44% of survey respondents (121 of 275) said they could pay for a procedure either straightaway or eventually.

Roughly equal numbers of people who said they would be affected by the proposals said they would – even if after a period of saving – pay for the procedure themselves (36%) compared with those who said they could not (40%).

Other (formal) responses The CCG received responses from a number of organisations against the proposals, including the B&NES Labour Group and the Men’s Health Forum, as well as questions from local councillors. B&NES Labour Group B&NES Labour Group emailed the CCG to share their concern on both the vasectomies/sterilisations and fertility proposals. They listed their concerns as follows:

Vasectomies and female sterilisations are a permanent form of contraception and should be available to all couples wishing to avoid an unplanned pregnancy once they have completed their families.

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Unlike all other long-term forms of contraception which are the responsibility of women, vasectomies enable men to take responsibility for avoiding unplanned pregnancies. This should be encouraged.

Men are statistically much less likely to seek medical advice and help than women. Restricting access to vasectomies will do nothing to encourage men to engage with primary health services.

Long-term hormonal forms of contraception involve uncertain side effects making them unsuitable for many women.

Although the group believes the services should be accessible for all, they did list some circumstances which could be considered exceptional:

When one partner has a genetic disorder that they do not wish to pass on to any offspring.

When pregnancy would threaten the physical or mental health of a woman.

When long term hormonal forms of contraception are unsuitable for a woman. Men’s Health Forum The Men’s Health Forum tweeted and wrote a news article (please see page 21 of this report).They also sent the CCG a formal response (please see Appendix 5 – Public feedback received by email/letter). Petition An online petition was set up in response to the proposal: Don’t limit access to contraceptive services. This was presented to the CCG at the public meeting held on 8 January, and the majority of people who had signed it were residents in B&NES. The petition has received 655 signatures to date.

6. Public ideas for other ways the CCG can save money A number of respondents said that they struggled to answer this question without knowing the full budget breakdown. However, a large number of people shared the following ideas:

Stop/limit funding certain services:

1. Stop/limit funding for ‘self-inflicted’ conditions related to obesity, smoking, alcoholism, drug addiction etc.

[Please note: the CCG is introducing a scheme to encourage people to lose weight and stop smoking before non-urgent operations].

2. Stop funding for other services, e.g. cosmetic procedures. 3. Consider what gets funded for elderly people.

Ask for more funding:

1. Appeal/stand up to central Government for more funding overall

[Please note: the CCG has a statutory duty to live within its means, but is vocal about

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the pressures it, and other similar localities, face].

Think of other ways to make money:

1. Think of more ways to make money rather than cut back 2. Get money back from ‘health tourism’ 3. Charge/fine people for missed appointments

[Please note: the NHS communicates with patients about the cost of missed appointments. The CCG monitors ‘Did Not Attends’].

4. Charge people who can afford services

Save money by reducing waste/staff wages:

1. Pay senior staff less 2. Stop employing temporary staff 3. Reduce red tape 4. Reduce resource wastage 5. Medicines reviews 6. Over the counter prescriptions 7. Spend on ‘social/hospitality functions’

Make changes to staffing/way services delivered:

1. Focus spend on prevention 2. Skill mix – use of pharmacists as triage/111/occupational therapists in primary

care 3. ‘Review purchasing’ [of services and equipment]

7. Conclusion CCG proposals to restrict access to fertility services The results of the consultation clearly show a great level of disagreement with the CCG’s proposals to restrict access to fertility treatment. The criticism was focused largely on the proposal to restrict access according to women’s age, making it available to those aged 23–35 years only. This was clear in the survey responses, emails to the CCG, formal responses from organisations and campaign groups with an interest in fertility issues, in social media comments and during face-to-face engagement. The angle taken in media interviews also reflected these criticisms, asking whether the proposals are fair to those they would affect most, in light of the financial gain anticipated. Many respondents were particularly concerned about the female age criteria in conjunction with the proposal to introduce a two-year duration of infertility for couples trying to conceive, as they felt this lowered the actual age limit for women being eligible for treatment to 33 years. The most common reason for objections to the age/duration of infertility proposals was that couples now tend to wait longer to start families, partly due to financial and housing pressures and women focusing on career progression before having children. By the time such women started trying to have a family and waited the proposed two years for it to occur naturally, they would be likely to be older than 35 years.

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Conversely, there was general support from survey respondents for the other proposed criteria. In particular, that all women and men receiving NHS-funded fertility treatment should have a healthy body mass index (BMI), and that there should be some upper age limit for the male partner. When looking at the results by different sectors of respondents – health or social care workers or members of the public; male or female; people living in B&NES or living outside B&NES – the following conclusions can be drawn:

Health and care workers were generally more supportive of the proposals than members of the public, in particular, the criteria for female and male BMI and the age of the male partner.

When disagreeing, health and care workers were more likely to state that the CCG’s policy should adhere to NICE guidelines.

Members of the public were more likely than health and care workers to state that the proposals are outright wrong or discriminatory.

Women were more likely than men to disagree about the change to the age criteria for women accessing IVF services, as well as the criteria around the two-year duration of infertility.

More men were in favour of the proposals as a whole.

When reviewing the results by area, respondents who did not live in B&NES were more likely to disagree with all of the criteria.

Those who live outside B&NES were more likely to state that NICE guidance should be adhered to.

The proposal on restricting access to fertility treatment attracted much attention from the media, charities, campaign groups, local councillors and via social media, with comments and coverage that was generally against our proposals. Again, the negative comments were mostly directed at the proposal on female age. This feedback and engagement, combined with the results of the survey, suggests that overall people do not support restricting fertility services, especially with regards to age of the female partner. CCG proposals to restrict access to vasectomy and sterilisation Overall, the results of the consultation show that people do not support moving both vasectomy and female sterilisation services to exceptional funding only. Looking at the face-to-face engagement alone, there was marginally more support for the proposals compared with people who responded to the survey. Respondents’ greatest concerns were focused on the cost of ‘unintended’ consequences for people who would be unable to access permanent contraception, i.e. unwanted pregnancies. Frequently, people asked the CCG to state what these costs could be, in order to be able to judge whether they outweighed the anticipated savings of the proposals. The CCG attempted to model such costs, using local maternity services data as a rough proxy for the cost of ‘unintended’ consequences (taking into account the antenatal, birth and postnatal costings, but not including costs of terminations), and found that it would not take many unintended pregnancies to cancel out the anticipated savings made by restricting access to vasectomies and sterilisations.

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However, this modelling should be viewed as high-level, hypothetical and unverified. There is no reliable way to predict how many people would unintentionally go on to get pregnant or impregnate their partners if they were unable to access a sterilisation or vasectomy, particularly in light of the many alternative methods of long-acting contraception available. Each of these alternative methods is significantly less expensive than a vasectomy or sterilisation, and costings for the most common options can be found on page 9 of Appendix 1 – FAQs. The modelling also does not take into account the financial, social and emotional impact of an unintended pregnancy which again, is impossible to model accurately. Other concerns about the proposal to restrict access to vasectomies and sterilisations included it being discriminatory for three distinct groups:

Women – unfair burden to place on women to take charge of contraception and potentially be subject to the (relatively uncommon) side effects of long-acting contraception.

Men – taking away their only option for permanent contraception.

Low-income families (those who may be unable to support children/more children), are likely to also not be able to afford to pay privately for sterilisation services.

There was some suggestion from respondents that the CCG should consider putting further restrictions in place to access these services; or to restrict one, but not the other. Both procedures were stated as an example of one that could be cut, and health and care workers were more supportive of withdrawing female sterilisations. When looking at the results by different sectors of respondents, to include those who were health or social care workers or members of the public; male or female; those living in B&NES or outside B&NES; a limited number of conclusions were drawn that differed from the main analysis of comments received. However, some points can be made:

Health and care professionals disagreed very slightly more about proposals to restrict access to male vasectomies compared with female sterilisations.

While both health and care workers and members of the public were concerned with unintended consequences, members of the public were more likely to mention the costs to individuals financially, and to their mental health; as well as making reference to the wider system.

For both vasectomies and sterilisations, slightly more women agreed with the proposals than men. However, this was still a minority in relation to those who disagreed with the proposals.

The main concerns about the proposals were the same for both men and women – that they are discriminatory and will result in costly unintended consequences.

More people from outside of B&NES disagreed with the proposals than those who lived in B&NES. However due to the small number of responses from those who were not resident in B&NES, this is not statistically significant.

The proposal to stop funding vasectomies and sterilisations also attracted a great deal of attention from the media, campaign groups, individuals, organisations with an interest, and from councillors in opposition. The themes from the coverage mirror those outlined here. All of this, combined with the survey and face-to-face results, demonstrate general public disagreement with these proposals (although not unanimous).