Chris Rudge on why the NHS needs to raise its game on transplants

The clinical case for organ transplantation is overwhelming, particularly in light of the dramatic improvement in transplant outcomes over the past 20 years. However, despite real progress, every year about a thousand people die before an organ becomes available.

For virtually all forms of transplantation, 90-95 per cent of patients are alive and well one year later, and between 50-75 per cent will still be well after 10 years. For kidney transplants there is very strong evidence that quality of life is improved by transplantation when compared with dialysis and increasing evidence from the US and, more recently from the UK, demonstrates that life expectancy is increased by transplantation for those patients deemed clinically suitable for the waiting list. There are currently no long-term alternatives to transplantation for patients approaching death with end-stage liver, heart or lung disease.

Since 2001/02, UK Transplant has provided funding of over£14m to NHS hospitals throughout the UK to increase organ donation for transplantation. This has been associated with an increase of 58 per cent in the number of kidney transplants from living donors performed each year, and an increase in the number of non-heartbeating donors of 300 per cent. Sadly, efforts to increase transplants from heartbeating donors have not been successful - the annual number has fallen by 9 per cent.

European comparison

For renal transplantation, the economic case for transplantation is also overwhelming. While there is currently no single national tariff for either haemodialysis or peritoneal dialysis, a figure of£30,000 a patient per year is realistic. Thus the NHS is currently spending nearly£190m a year on dialysis for the 6,278 patients actively waiting for a kidney transplant.

If every one of these patients currently had a functioning transplant (maintenance costs of approximately£5,000 pa), the annual saving would be of the order of£160m. For liver, heart and lung patients waiting for a transplant there are hidden costs running into many thousands of pounds per patient - many of them spend days or weeks as hospital inpatients, often including time in intensive care, that could be saved by earlier transplantation.

While the UK Transplant funding (received directly from the UK health administrations) has produced notable benefits in some aspects, the overall position remains deeply unsatisfactory. The current overall waiting list stands at 7,075. The UK's organ donation rate compares unfavourably with those of most western European countries. In Spain, for example, there are three times as many organ donors per head of population as in the UK.

UK Transplant is now part of the NHS Blood and Transplant Authority, which is committed to the development of radical proposals to improve the situation. A very significant and welcome development is the Department of Health's task force on organ donation - currently being established under chair Elisabeth Buggins and due to report this summer. This is an opportunity for a wide-ranging review, and without pre-judging the outcome of the task force it is clear that improvements could be made in a number of areas.

Promoting donations

However, one issue is already clear. Unless and until every level of the NHS recognises that everyone, including community groups, voluntary sector groups and faith communities, can and must play a role, the problem will not be solved. Donor co-ordinators, transplant units, NHSBT cannot alone produce more organ donors as if by magic.

Every large general practice will have patients who are receiving dialysis or who are waiting for a transplant. Every PCT will be involved in commissioning and funding dialysis. Every acute trust will from time to time see patients with severe organ failure that are referred to the regional transplant centre. Every strategic health authority is overseeing specialist commissioning arrangements that will affect both donation and transplant rates in their region. Everyone can play a part in promoting organ donation.

The recently introduced Human Tissue Acts make the wishes of the individual paramount in agreeing to organ donation and emphasise the importance of the NHS Organ Donor Register - this must be promoted at every opportunity. Primary care trust and NHS and foundation trust boards can ensure that every potential organ donor is recognised, referred to the donor co-ordinator teams, and that the relatives of the donor are approached.

The right people must approach the relatives at the right time and in the right way - and the general public must respond by reducing the 40 per cent of donor relatives who currently refuse consent for donation. The problem can be solved, and when it is, thousands of lives will be saved and the NHS will save millions of pounds.

Chris Rudge is managing and transplant director of UK Transplant.