After yet another damning report on our rudderless health service, Dara Gantlywonders what innovations will be necessary to incentivise donors and care for those awaiting life-saving transplants, despite some encouraging statistics.
Another week; another inquiry into the (mis)management of our health service. The damning report into the circumstances that led to the failed transportation of Meadhbh McGivern for transplant surgery in London found that the system for transferring patients abroad in urgent circumstances for treatments not available in Ireland was “not designed to be reliable”.
“The overriding finding that contributed to Meadhbh’s failed transportation was that no one person or agency was in charge or accountable for the overall process of care and transportation for Meadhbh,” the HIQA report concluded.
Unfortunately, this absence of accountability could be viewed as emblematic of so many of the ills afflicting our health service. There was “no evidence” that the main players understood or managed the risks. Instead, “confusion” existed between the bodies involved (in this case the National Ambulance Service and Our Lady’s Children’s Hospital, Crumlin). Proper contingency plans were not put in place, while others charged with organising parts of the transportation did not have the required skills and competencies to effectively undertake their role. Is it just me, or does all this have a sad ring of familiarity about it?
The report does state that every person who was involved on the night, as well as those interviewed by the Authority, were visibly distressed at how the events unfolded, and all expressed their commitment to improving the arrangements to ensure that this did not happen again. Indeed, the immediate response from the various organisations has been encouraging. All existing protocols have been revised by the HSE, and Crumlin Hospital has developed a transport plan for each patient on the organ transplant list who is living at home.
HIQA made 17 national recommendations in its review. Key among these is the establishment of a National Aeromedical Co-ordination Centre, within the HSE National Ambulance Service, which will co-ordinate all of the transport of patients by air and become the new single point of accountability. HIQA wants this established within two months and it is important that the pressure is kept up to ensure that this target is met.
Equally important is that some movement is seen on the commitment made in the programme for government to change the process around organ donation to an opt-out system. While a direct correlation between rates of donation and presumed consent is not completely unequivocal, Spain — which introduced presumed consent legislation in 1979 — is viewed by many as having the ‘gold standard’ organ procurement system. However, as Dr Deirdre Madden pointed out in a recent letter to IMT (July 8, 2011, http://bit.ly/nvuSdT), increases in organ donation are due to a number of factors, including legislation, availability of donors, organisation and infrastructure of the transplantation service, investment in healthcare and public attitudes to, and awareness of, organ donation.
Organ transplant support groups have expressed reservations about the proposed change in legislation. However, in a ‘clarification’ on the move, the Minister for Health, speaking in March, said he wanted to make it clear that the Government’s opt-out proposal was “merely a way of starting a conversation”, when the issue of organ donation after death arose in hospitals. “The express permission of the family is crucial. No organ removal will ever happen against the wishes of a family,” stated Dr James Reilly.
'Twelve patients died last year waiting for liver transplants, which would be about three times more than in other years'
A quite different conversation altogether around organ donation was started recently by Sue Rabbitt Roff from Dundee University, when she questioned whether it was time to explore ‘regulated paid provision’ for live kidneys. Writing in the British Medical Journal (BMJ 2011; 343:d4867), Roff advocated that the standard payment would be equivalent to the average UK annual income of around £28,000 (or €32,000).
This “would be an incentive across most income levels for those who wanted to do a kind deed and make enough money to, for instance, pay off university loans,” she says. With three people on the kidney transplant list dying in the UK every day and thousands more attending dialysis units, Roff says there needs to be a public debate on “regulated paid provision” for live kidneys.
Drastic stuff, you would agree — although 2010 was a drastic year for donor numbers in Ireland, which fell by 35 per cent. Twelve patients died last year waiting for liver transplants, which would be about three times more than in other years.
Thankfully, preliminary organ donation and transplant figures so far this year have been described as “exceptionally outstanding”, already outstripping figures for the whole of last year in some instances.
As revealed in IMT last month (July 15, 2011, http://bit.ly/qafDJD), there were 95 kidney transplants up to June 30, just three shy of the total for the entire previous year, as well as 34 livers in the first six months of this year (compared to 38 in 2010).
Heart (four) and lung (six) transplant figures up to June already superseded those for 2010 at three and six, respectively, and there have also been 14 living kidney-donor transplants from 14 donors so far in 2011.
It seems Roff’s conversation might be a bit premature, although with more than 650 people in Ireland awaiting life-saving organ transplants including heart, lung, liver, kidney and pancreas — and the numbers on dialysis ever increasing — such radical suggestions will no doubt be aired again. Could such an idea ever fly? For now, at least, it should be firmly grounded.
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