NHS opt-in transplant policy at risk due to cuts and staff stress

Plans to save hundreds of lives by making everyone in England a potential organ donor could fail because hospitals are so short of transplant surgeons and specialist nurses, the NHS’s own analysis of the policy has revealed.

Lives could be lost because teams of organ retrieval specialists are already under “extreme stress” and understaffed transplant centres are struggling to keep up with existing demand, according to NHS Blood and Transplant’s (NHSBT) impact assessment of switching to a system of presumed consent.

Theresa May has thrown her weight behind ambitious plans to help the 6,000 seriously ill Britons who are awaiting an organ transplant by making organ donation at death something the 55 million people in England have to opt out of rather than choose to do, which is the current system.

She made clear last year that she favoured “shifting the balance of presumption in favour of organ donation” from opt-in to opt-out because it could save up to 500 people a year dying unnecessarily. The legislation required to make the change is going through parliament in a private member’s bill being sponsored by the Labour MP Geoffrey Robinson, which has commanded support across the political spectrum.

Doctors’ leaders have hailed presumed consent as a “life-saving move” which will tackle the three avoidable deaths that occur every day across the UK because of the shortage of organs.

But the unpublished NHSBT document, obtained by the Guardian, warns that hospitals are so short of key specialists and equipment needed to keep organs viable that the NHS may not be able to harvest all of the increased number of organs that is expected after presumed consent becomes law.

The UK has fewer doctors and nurses than many other comparable countries both in Europe and worldwide. According to the Organisation for Economic Co-operation and Development (OECD), Britain comes 24th in a league table of 34 member countries in terms of the number of doctors per capita. Greece, Austria and Norway have the most; the three countries with the fewest are Turkey, Chile and Mexico. Jeremy Hunt, the health secretary, regularly points out that the NHS in England has more doctors and nurses than when the Conservatives came to power in 2010. That is true, although there are now fewer district nurses, mental health nurses and other types of health professionals.

NHS unions and health thinktanks point out that rises in NHS staff’s workloads have outstripped the increases in overall staff numbers. Hospital bosses say understaffing is now their number one problem, even ahead of lack of money and pressure to meet exacting NHS-wide performance targets. Hunt has recently acknowledged that, and Health Education England, the NHS’s staffing and training agency, last month published a workforce strategy intended to tackle the problem.

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One section outlines problems affecting the ability of NHS National Organ Retrieval Service (NORS) teams – groups of surgeons, nurses, paramedics and operating theatre staff – to retrieve body parts quickly from people who have just died, so they can improve, extend or save other people’s lives.

“[NORS teams are] already experiencing extreme stress in the system. Any additional capacity requirements will have a high risk of failure to mobilise teams within required timescales, risking potential loss of transplantable organs.”

Similarly, in a section dealing with England’s 27 transplant units, NHSBT – the agency that oversees organ donation UK-wide – warns of a potential “failure to transplant all retrieved organs arising from an increase in donors” because of a lack of “staff [and] ward capacity”. It adds that “it will take several years before maximum anticipated increase in donor activity is realised, but the transplant capacity is already struggling to meet demand in some units”.

The impact assessment also warns of a high risk that hospital pathology services may prove inadequate, leading to “failure to support donation and transplant processes, leading to loss of potential donation/transplants”.

The 18-page analysis also reveals that:

• Transplant units will need to hire 30 nurses who specialise in organ donation as well as extra managers to cope with increased availability of donor organs.
  

• Hospitals will need more perfusion machines, which keep blood pumping around the organ or organs to be taken from someone who has recently died, in order to ensure they can be transplanted. In particular, units need more “circuits”, the tubes that pump blood into and out of the deceased body, so organs can be kept alive.

• NHSBT’s operational hub at its Bristol headquarters, which supervises organ donation on a 24/7 basis, will also need more staff.

It is estimated that switching to presumed consent will yield about 100 extra donors per year and another 230 transplants taking place, the document says. Although 500,000 people a year die in the UK, only 5,000 of them die in circumstances where their organs can be retrieved and used, NHSBT said.

More people have signed the organ donor register in Wales since it introduced the system in 2016, though it is unclear if the move has led to more organs becoming available.

Matt Hancock, who last week replaced Jeremy Hunt as the health and social care secretary, has hailed the ongoing passage of the bill as “an important step forward in making organ donation easier and more available for those who desperately need it”.

Ministers plan to fast track the bill when it returns to the Commons for its third reading in the autumn with a view to presumed consent coming into force in January 2020. They will also fund a £12.5m information campaign and £1.25m leaflet drop to alert people to the change and what it means.

Roberto Cacciola, NHSBT associate lead for organ retrieval and a transplant surgeon in London, said: “The UK has a lower donation rate compared to Spain, France and US. This means we have fewer organs available and fewer transplants. Patients waiting for a heart, liver, kidney or lungs inevitably don’t receive the transplant in time and sadly die while waiting for an organ being available.”

Between 2010-11 and 2016-17, health spending increased by an average of 1.2% above inflation and increases are due to continue in real terms at a similar rate until the end of this parliament. This is far below the annual inflation-proof growth rate that the NHS enjoyed before 2010 of almost 4% stretching back to the 1950s. As budgets tighten, NHS organisations have been struggling to live within their means. In the financial year 2015-16, acute trusts recorded a deficit of £2.6bn. This was reduced to £800m last year, though only after a £1.8bn bung from the Department of Health, which shows the deficit remained the same year on year.

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On the capacity of NHS organ donation, retrieval and transplantation services, Cacciola said: “They have always suffered shortages of personnel and this has accrued since Brexit and the overall attitude of the Home Office towards doctors and nurses from in and outside the EU.

“Increasing the number of potential donors and their assessment would increase the workload on the already overstretched services with regards to intensive care beds, A&E department capacity, the numbers of both specialist nurses for organ donation and also transplant surgeons for both organ retrieval services and transplantation and other resources,” Cacciola added.

Robinson welcomed the fact that the Department of Health and Social Care’s consultation into presumed consent, which has also been seen by the Guardian, shows there is little public opposition to the plan. Only one in four people think relatives should be able to override the wishes of someone who has died after indicating their wish to donate their organs.

“The public have come out in force to give their overwhelming support for the new system my bill proposes, which the NHS projects will save hundreds of lives a year,” Robinson said.