HC Deb 26 February 1988 vol 128 cc557-83 9.34 am
Mr. Gwilym Jones (Cardiff, North)

I beg to move, That this House welcomes recent advances in transplant technology and in the availability of transplant operations through the National Health Service; especially welcomes the Government's commitment to secure further progress in this vital area; notes that the recently published Hoffenberg Report recommends steps to improve the supply of donor organs; recognises that it is the shortage of suitable organs satisfactory for donation that limits people's opportunities to enjoy a greatly enhanced quality of life; calls for action to be taken to achieve further improvements by more effective procedures which, whilst being sensitive to the needs of patients, relatives, the bereaved, doctors and other health professionals, effectively identify potential donors and increase the availability of donor organs. I am pleased to have this opportunity to introduce a short debate on the very important subject of transplant notification procedures. I am pleased to see my hon. Friend the Under-Secretary of State for Health and Social Security in her place. I know that she had to reorganise her engagements to be here for this debate, and I regard that as typical of the generous and willing spirit in which she tries to assist all constructive debate on health. I am grateful to her.

If necessary, I shall declare my interest, although it is not in any way a pecuniary interest. I am privileged to be involved in the Kidney Research Unit Foundation for Wales, which, two years ago, invited me to become one of its vice-presidents. I was proud to accept that position and I am proud of KRUF's contribution to kidney treatment in Wales.

The figures clearly show that, since 1984, there has been a marked and welcome improvement in kidney treatment in Wales—even more marked than the improvement in England. That is the result of a new approach to kidney treatment at two units in Bangor and Carmarthen in which KRUF has played a significant part. In turn, the two new units have played a significant part in the Welsh figures—so much so that the new approach, if properly followed in Wales and elsewhere, could ultimately eliminate all the shortfall in dialysis treatment, probably without the need for extra machinery or staff.

Kidney transplantation is the ideal conclusion to dialysis treatment. I contend that not enough progress is being made in this vital treatment. We are not capitalising on the tremendous fund of good will among the public. The number of transplant operations is increasing and will continue to increase, but so, too, are the waiting lists for transplant operations. We are not making the best use of our resources, by which I mean donors, potential donors and the willingness of the public to facilitate transplantation.

Why do we not capitalise on the known good will of the public? It is perhaps useful to consider a recent survey carried out by Cambridge university of 1,500 adults' attitudes towards transplantation. On being asked, 80 per cent.—a very welcome proportion—gave gave their approval for the transplantation of any or all of their organs. However, on further questioning, it was discovered that only 23 per cent. of the sample had donor cards in recognition of their willingness to become donors. Furthermore, only 14 per cent. carried those donor cards. We might rely on donor cards to indicate a person's wish to donate organs at the crucial time, but the survey clearly shows that the cards do not provide an adequate means of identifying potential donors. Donor cards should not be written off, but they are certainly not the complete success that we should like them to be or that they were perhaps envisaged when they were first introduced some 17 years ago.

Donor cards are not the only device to promote the needs and benefits of transplantation. There is another Welsh success, again involving KRUF. In 1986-87 KRUF carried out two associated operations. First, it set up Lifeline Wales — a computerised system. It leafleted every home in Wales exhorting Welsh people to register on Lifeline Wales' computer their willingness to donate their organs.

The Lifeline Wales computer could then be consulted by on line computers in intensive care units to ascertain donor wishes. KRUF also held symposiums in 1986 and 1987 and, as a result, it was able to involve the consultants and nurses of all the intensive care units and to expound the benefits and needs for transplantation. Such an achievement would not have been possible as a result of one symposium.

As a result of the increased awareness and publicity of the need and benefit of transplantation, there was a marked increase in the number of such operations carried out in Wales in 1987. Can such an improvement be continued? The achievements of the symposiums and Lifeline Wales cannot be easily repeated. The operations were carried out at no small effort or cost. Indeed, a novelty factor may have been involved that could be lost in repetition.

I am sure that the House will recall that I sought to introduce a ten-minute Bill, the Transplant Notification Bill, on 3 February. Ideally, I would prefer that, this morning, I was moving the Second Reading of that Bill. I know that that is not possible, but I believe that it is pertinent to try to put forward the arguments and objectives of my Bill. The Bill sought to introduce what can popularly be described as "required-request legislation". That legislation would ensure that the necessary questions to ascertain donors' wishes are asked at the right time. I believe that such questions are not asked often enough.

In essence my Bill was a response to the Hoffenberg report—the results of a working party from the medical royal colleges set up on the invitation of the Department of Health and Social Security under the chairmanship of Sir Raymond Hoffenberg. I am disappointed by the conclusions and recommendations of that report. I do not believe that there is likely to be an improvement in the progress of transplantation operations, for which we all wish, as a result of that report. I am especially disappointed that the report did not argue that we should grasp any significant nettle that may hold out hope for progress.

The report describes the shortfall in organs for donation — that was the essential reason for the establishment of the working party. It refers to the important criteria relating to brain-stem deaths — an essential part of the practicalities involved with organ removal. The brain-stem death test was first established in 1976 and has been reaffirmed in 1979, 1983 and 1986. The report defines when organs need to be removed. Hearts, livers, pancreases and lungs must be taken from a heart-beating donor—the heart is maintained only as a result of the patient being in intensive care. Kidneys need to be removed at the same time or immediately after death, whereas corneas can be removed up to 12 hours after death.

The report estimates the number of brain-stem deaths that usually occur each year. It also gives the transplant figures for 1986 and the first quarter of 1987. In its introduction, it makes a vital projection relating to kidney transplants. Kidney transplants are our greatest need and represent the greatest number of transplantation operations carried out. The report projects that our total need for kidney transplants could be fulfilled if a greater proportion of the usual number of brain-stem death cases were to become kidney donors.

The report lists eight reasons for the shortfall in organ donations. The first is doubt about the success of the transplantation programme. I agree with the report that that can no longer be considered a valid reason for the lack of organs for transplant. I believe that the public are now aware of the benefits of transplantation; that contributes largely to public goodwill towards such transplantation. The report also states that doubt about the criteria for brain death contributes to the organ shortfall. It refers to certain publicity that has led to worries about brain-stem death criteria. As a consequence, there has been a marked downturn in the number of organs coming through for donation. The report emphatically states that there can be no question that survival is in any way relegated to second place after the need for transplant organs. With equal emphasis, the report says there is no possibility that organs can or will be taken from a live patient.

The report also refers to lack of medical experience and knowledge contributing to the shortfall. The report says that most doctors do not have frequent experience of brain-stem death or transplantation. It believes that doctors will not even encounter such cases once a year. However, the report does not state whether it means most doctors, or most doctors in intensive care units — I believe that there is a significant difference between the two categories.

The report also says that transplantation operations may be affected by the pressure on intensive care beds. There are other priorities with which an intensive care unit must deal that might frustrate the opportunities for organ removal. The report makes the somewhat unusual comment that, if relatives request organs to be donated, the move into an intensive care bed "should be considered". I believe that such a "consideration" is an insubstantial approach to a most important matter.

The report also refers to the effect of limited time—several hours must be spent in making the arrangements for transplantation. However, I believe that our transplant teams are well versed in all that is involved and the crucial necessity to ensure that transplantation timings coincide. Indeed, we are all aware of a recent example on television when a donor heart and the recipient had to be brought by aircraft from different parts of the country to Papworth hospital. I believe that transplant teams are geared up for such operations and that there should be no fear about limited time. The report also mentioned the problems of limited theatre time; that relates to the pressure on intensive care beds and the other emergencies with which operating theatres must deal.

Another reason listed for the shortfall in transplants—a new area for consideration—is that of costs. There is an increasing and justified need for clinical budgeting and an awareness of cost within the Health Service that has implications for other treatments.

The final reason suggested by the report for the shortfall was medico-legal constraints, but it believes that such constraints do not represent a problem. I am struck by the thinness of some of the reasons for the shortfall and the omission of what I consider, in common with many others, to be the main problem with regard to transplantation—the need to ask the right questions. Are those questions being asked? If not, why not?

At the beginning of the report, it states that a questionnaire was sent to all intensive care units. However, that questionnaire and its results have not been published— we do not know what has been gained from it. Three oral evidence sessions were held by the Hoffenberg working party, and evidence taken from another 37 individuals, but that has not been published. If all such information had been made available, we would have a much thicker document than the present six pages. Given the importance of the subject, I believe that the report should be thicker.

Recently, another survey has been carried out for the BBC television programme "That's Life". That survey was sent to 200 intensive care units and asked consultants and senior nurses why the important questions are not asked. Three reasons were given. The first was a dislike for adding to distress. There is a natural desire not to increase the distress of relatives at a very emotional time. The second reason given was the lack of training in approaching relatives at that crucial time. The third reason was bad publicity about brain death and transplants. I am surprised at that third reason from consultants and nurses in intensive care units. I feel that that survey, and the one pursued by the Hoffenberg working party deserve to be pursued further to see what else we can learn.

I am even more concerned about a statement from the British Organ Donor Society. It makes the following comment: We understand that there are some intensive care units where, as a matter of internal or personal policy, families will not be approached concerning organ donation. The three reasons given in the survey are worthy of consideration. The statement from the British Organ Donor Society suggests a negative position that frustrates a purpose that we should all like to see pursued.

There are 14 numbered paragraphs of recommendations in the Hoffenberg report, which are largely in line with the reasons given for the shortage of organs. The report reaffirms the working party's conviction about the brain-stem death criteria. The working party report states that brain death means death. It recommends the important need for training of medical students and postgraduates in four sectors — the criteria for brain death, the success and demands of organ transplantation, communication with bereaved relatives — that is a particularly important matter — and training in procedures to arrange for transplantation.

The report recommends that clearly defined national and local criteria for the acceptance or rejection of organ donation should be established. It makes the specific point that paragraph 6 of the code of practice on organs for transplantation needs modifying.

In line with the recommendation for training for medical students and postgraduates, the report recommends that there should be similar training for nurses— in assisting with the determination of death, with the removal of organs and in communication with relatives.

The report recommends that theatre arrangements should be simplified. Reference is made to the Cambridge initiative, whereby a single team achieves multiple organ removal. That must be a simpler and better approach to organ removal.

The report recommends that district health authorities should be reimbursed for the cost of providing donor organs. That is an important matter, because it relates to at least three of the reasons that have been listed for the shortage of organs. The main reason given in the report is that entitled cost, and the needs with regard to clinical budgeting, the awareness of cost and the implications for other treatments. There are the further reasons of pressure on intensive care beds, the other priorities that must be considered and the limited theatre time, with the implications that that has for other emergencies.

The report recommends that corneal donation should always be encouraged. It says that there is a need to alter the wording on donor cards.

Running through the recommendations is an advocacy of the need for better information about transplants and their benefit. It says that better information should be provided on a continuing basis inside hospitals and outside hospitals for the general public. Essentially, it is an ongoing public relations campaign to achieve improved transplantation.

On the fundamental matter of the asking of questions about a donor's wishes, the report is not brief, but it is still not as substantial or as positive as it might be. It talks about means that should be found to ensure that donor's wishes are better known. It uses the examples of the Lifeline Wales project and other similar projects throughout the country as possible ways of achieving that objective. It says that organ donation should always be considered. To my mind, that is a perfectly obvious statement.

The report comes down against an opting-out procedure. I would not wish to differ with that argument because with transplantation we should always maintain the important principle of the gift of life, which benefits the giver as well as the receiver, and which in turn comforts the relatives of the deceased.

The report comes down against the concept of required request, but it does not offer any evidence or argument as to why we should not pursue it. Instead, as a stop-gap, the report calls for an audit of the diagnoses of brain death, of the numbers of transplants and the reason for the shortfall. It expects that the senior doctor should make the first approach on all occasions to ascertain a donor's wishes. It recommends that each district health authority should develop a policy for transplantation.

With regard to the Hoffenberg report, I would say, "Fine so far, but not far enough." I have a vague feeling of superficiality about it. It has skimped the main problem of the questions that are not being asked often enough. Perhaps the survey would have told us more, but it has not been published. If it had been, we might be aware of another problem that has recently been highlighted by the heart transplant surgeon, Mr. John Wallwork. He sought to define the knock-on effect of the shortage of hearts for transplantation. He said that if hearts could only be transplanted earlier into a fitter patient, it would require less nursing and less caring than is being devoted at present to looking after a less fit transplant patient. That extra nursing and caring could be devoted to an increased number of transplants. I think that that is the most relevant point about that knock-on effect.

Equally relevant is the projection that Mr. Wallwork has made that one in five people on the waiting list for heart transplants may be expected to die before an operation can be carried out. That is an improvement, because until recently it was expected that one in four might die before a transplant could be carried out. We do not know whether any of those aspects were covered in the survey that the working party considered or in the evidence that it took.

The report abruptly comes down against required request, but we are no better informed about it. I suspect that lurking within the recommendations of the Hoffenberg report is the spurious argument that required request interferes with clinical freedom. That spurious argument has yet to be defined in a meaningful way. Clinical freedom concerns judgments about a patient's care. I cannot see how wishes for donation interfere with a patient's care. In that context, Mr. Ross Taylor of the Royal Victoria hospital in Newcastle upon Tyne said: By not legislating we are protecting non-existent rights of people in intensive care units in the form of doctors and nurses, disregarding very definite rights of donors and donor families who are not being asked. I should add that we are disregarding the rights of people who are waiting for transplants. Mr. Taylor goes on to estimate that there is potential for increasing the number of transplants fivefold.

Professor Arthur Caplan of the university of Minnesota is even stronger in his defence of required-request legislation. He has good credentials because, besides being professor of medical ethics at the University of Minnesota, he has been involved with the setting up of required-request legislation in various states of America. That legislation is now in place in the majority—33—of the states. He argues that required-request has nothing to do with restriction or coercion; he says that it offers a choice. Already, thousands of people in the United States have benefited from the coming to pass of required-request legislation. He feels that that is the finest justification for its introduction.

Professor Caplan said that he would say to doctors: Take seriously your obligation as healers. Take seriously your duty to transform tragedy into something good. If it's not legislated, then by choice, I would hope that the British Medical Association would very quickly decide to put the policy in place on its own, and it could—there's nothing to stop them from doing it anyway. Although I have great reservations about the Hoffenberg report, I by no means totally condemn it. It contains much of great value. I look forward to finding out whether my hon. Friend the Minister can tell me about progress in implementing the important recommendations in the report. By "important considerations" I have in mind the recommendations that each district health authority should institute an operational policy for transplantation and the recommendation that training should be provided for medical students, postgraduates and nurses in all the various areas, not least in communicating with bereaved relatives. Importantly, cost is highlighted in the report. There is the recommendation that district health authorities should be reimbursed for the cost of organ removal.

None of us would want aspects of clinical budgeting or the awareness of costs to be the cause of frustrating further expansion in transplantation. Certainly, there are financial implications, not just in cost but in savings to the Health Service. For example, kidney transplants are the ideal conclusion of dialysis. It is estimated that dialysis costs an average of £15,000 a year for each patient. That expenditure would not have to be maintained and would be a saving that could be applied to further patient care in the NHS.

There is also the aspect that my hon. Friend the Minister recently and rightly observed. Each successful transplant means that an ill person becomes a fit person. There is a greatly improved quality of life and patients would probably resume their occupation or take up an occupation, in turn making a contribution to our economy, at the very least by paying tax. The recommendation about cost in the Hoffenberg report certainly needs to be pursued.

I should remind the House of the minor point about altering the wording on donor cards. The card refers to the removal of eyes. However, it is not eyes that are removed but corneas. The Hoffenberg report has drawn our attention to that possibly off-putting effect, which may worry some people.

We should go further than the Hoffenberg report. I urge my hon. Friend the Minister to add lustre to her reputation and to be remembered for a long time as the Minister who seized the banner of required-request and achieved tremendous progress. I have referred to some statistics but it is not enough just to use bald statistics. We are dealing with human beings.

With that in mind, I refer to a recent tragedy that is relevant to the debate. It was written on the front page of the Fareham and Gosport Street Life of Thursday 18 February. It said: Genna Trapp died a month before her third birthday because doctors could not find a donor to replace her damaged liver … And they now say Genna should never have died. A change in Britain's transplant laws could have saved her, they say. Liver specialist at King's College Hospital in London, Doctor Roger Williams watched Genna die … He wants drastic changes to make more livers available. 'The law should be changed so that people are automatically asked about donating organs when a child dies', he said. 'It's a system that works in America and it is called Required Request. There are children like Genna dying and they will continue to do so unless this happens. It is a terrible waste.' My fear is that our waiting list for transplants could continue to increase beyond the level of potential donations. The current waiting list for kidneys is 3,485. Last year, 1,566 kidney transplant operations were carried out. However, our waiting list will not decline at the rate of 1,500 a year, because each year more patients are diagnosed as being in need of dialysis and, eventually transplant. It is likely that the waiting list, even with that level of operations being maintained, will grow by 1,000 per annum. The Hoffenberg report estimates that there are 4,000 brain-stem deaths each year. That means 8,000 kidneys. If our waiting list continues to increase by 1,000 per year, in what year will that waiting list be greater than the potential number of kidneys available for transplant?

There are grotesque alternatives that are being pursued. Attempts are being made to use pig valves and baboon hearts for transplant purposes. For instance, a baby was kept alive in 1984 for 20 days by the transplant of a baboon's heart. I learned this week of a $3 million grant project in the United States of America for the farming of chimpanzees so that their hearts and kidneys can be taken for transplantation. We know of the trade in India of purchasing kidneys from healthy poor people.

Occasionally, some of those techniques might be indispensable in adding to the sum of our medical knowledge, but in general I feel that we are going down dangerous roads. We are taking immoral and unethical avenues that we should not be pursuing. The detestable trade in India of selling kidneys and preying on the poor is but a short step from even more vile practices such as murder, body snatching and the involvement of organised crime. We may detest those practices, but we recognise that desperation for transplants is the essential motivation.

On balance, I acknowledge and praise the tremendous progress that has been made in transplantation and the continuing increase in transplants. It may be said that over 8,000 people are now alive and enjoying a greatly improved quality of life who might not be alive if it were not for the transplant programme. I acknowledge and praise our Government's commitment to wanting to achieve further progress. At the risk of repetition, it is only required-request that will make significant progress. Substantial authorities are in favour of required-request, as are various medical experts. It is already in operation in various states of America.

Arguably, there is overwhelming support for required-request. We can already show good will towards transplantation and a wish to see it expanded further. Closest to home, the chairman of the Kidney Research Unit Foundation for Wales, Mr. Wilkinson, has told me about discussions at the Elephant and Castle in which he participated, where the majority favoured the earliest move to required-request legislation.

Against that is the position set out in the Hoffenberg report, of essentially trying to continue to rely on the voluntary approach, when it must be staring us in the face that the voluntary approach is not succeeding and when the demand on the waiting list is likely to increase. So much has been done and continues to be done. However, I argue strongly that we should grasp the nettle of required-request.

10.8 am

Mr. Ray Whitney (Wycombe)

I convey my warm congratulations to my hon. Friend the Member for Cardiff, North (Mr. Jones) on the excellent contribution he has made to our debate and to his sustained leadership of a campaign on a crucial crusade which will, when he succeeds—I hope that it will be only a short time before he does so—enhance the quality of life of so many of our fellow citizens.

I also congratulate the health authorities in Wales which, in many areas, show a commendable initiative that could well be copied by other regional health authorities in the United Kingdom. For example, Heartbeat Wales is at least two or three years ahead of the rest of the United Kingdom. The results of Heartbeat Wales have been shown in the coronary heart disease statistics. That is another area in which we grievously need to make progress.

When I had the privilege of filling the post now so splendidly filled by my hon. Friend the Member for Derbyshire, South (Mrs. Currie), it became clear to me that organ transplants were a technique that should be looked at positively. The more I examined it, the more I became convinced that it was the way to go. I therefore went to the United States two or three years ago and was deeply impressed by the progress that individual states of the Union had made. Their record since then amply justifies the optimism that most of the proponents of the required-request system then had. It was partly my own enthusiasm which led to the creation of the committee under Sir Raymond Hoffenberg. I share the disappointment of my hon. Friend the Member for Cardiff, North at the failure of the Hoffenberg report to go any further.

Those of us who have examined the issue recognise the immense sensitivities and difficulties about the time of bereavement, and the great anxiety of the next of kin and of the doctors and nurses concerned with the case. We must also recognise that those of us who are not in the profession would offer views on the clinical and medical aspects only with the greatest timidity and sensitivity. That being said, I believe that, for all the reasons that my hon. Friend the Member for Cardiff, North mentioned — I shall not weary the House by repeating them— we must re-examine what we should do.

Of all groups in the country, members of the medical profession are the most conservative. I am afraid that my hon. Friends at the DHSS cannot just sit back, accept the medical advice and leave it at that. There are clinicians who know of the immense advantages for quality of life and rapidity of treatment — not to mention economic savings in the Health Service — but the balance of medical opinion will always continue to push in the opposite direction. We need leadership from the Ministry and the Department— and from us, as legislators. It is for that leadership, positive encouragement and active promotion that we look to my hon. Friend the Under-Secretary of State and my right hon. Friend the Secretary of State.

10.13 am
Ms. Harriet Harman (Peckham)

I hope the House will forgive me, but I almost completely lost my voice yesterday, and it has only partly returned this morning. I shall be brief and, I hope, to the point.

I warmly thank the hon. Member for Cardiff, North (Mr. Jones) for bringing the issue back to the House today and for the points that he made in support of his motion, with which I almost entirely agreed. He was right to say that there is agreement that more action is needed and that the situation is unsatisfactory. Advances in transplant medicine have meant that thousands of people, who would otherwise have died or been condemned to lead miserable life, can live and enjoy an almost normal one. Many people, because of the shortage of transplant organs, cannot benefit from transplant surgery and must wait a long time in misery, or die while they are waiting. So there is general recognition that something more needs to be done, but there is no agreement about what.

Some would argue that organs should be taken unless the deceased's relatives veto that action. That approach has been adopted in some states in the USA. It dramatically reduces the waiting lists and increases the supply of organs available for transplant. However, some people fear that, however watertight we try to make the system for ensuring that a veto has not been exercised, some people's organs will be taken, despite profound objections on the part of relatives who did not find out in time.

The Hoffenberg report makes nine recommendations, which include further publicity and education but essentially leave the structure of the system unchanged. The Government should adopt all the proposals in the Hoffenberg report and implement them straight away. I also understand the concerns that the report's proposals do not go far enough, will not ensure that enough organs are available for transplant, and will not significantly reduce waiting lists. Required-request is a middle way between requiring people to opt out with a veto and leaving the position as it is now.

The hon. Member for Cardiff, North discussed the required-request system, distinguishing it from a voluntary one. I think that the required-request system remains a voluntary system because, after the request has been made, the organs are taken for transplant only if they are volunteered by the relatives. It would become an obligation for the doctor to consider whether an organ donation would be possible, and if the doctor thought that the organs were suitable for donation the obligation would be on him to ask the relatives whether the organs could be made available. Some have expressed concern that that would upset newly bereaved relatives, but I believe that if there were a statutory obligation it would help doctors. They would merely be carrying out a task that they were obliged to do. That would assist them in approaching relatives and making the request. Similarly, doctors ask someone for consent before an operation because there is a legal requirement to do so, and people understand why they are doing it. It does not necessarily mean that they think things will go wrong. It is a formal procedure that people understand doctors must go through.

If doctors explained to relatives that they were required to request the organs and that the decision was entirely up to the relatives, that would be a straightforward procedure which I would welcome. There is no risk in that approach that organs would be taken against the wishes of the relatives, because they would have to be asked. There would also be no risk of relatives, who might have wanted the organs to be donated, not being asked. We should be concerned about that, too.

This is not a substitute for a proper public information campaign about the importance of organ donation and the transplant programme. The required-request system should be accompanied by a public information campaign about the possible benefits for those who have transplants. I urge the Government to accept the approach recommended by the hon. Member for Cardiff, North, and to go further than that. They should do more to promote the development of bereavement counselling and to train hospital staff to deal with relatives who have recently been bereaved. At the same time as adopting the required-request approach, I want them to carry out research into the long-term effect on relatives who have allowed organs to be used for transplant. Often, recently bereaved people's feelings change. We might find that people feel a greater degree of gratitude if they have the opportunity to donate their deceased relatives' organs for transplantation.

We need a better understanding of the short-term effect on people. We also need a longer-term research programme to examine the effect on bereaved relatives, particularly parents, of making organs available for transplantation. I urge the Government to make sufficient finance available to district health authorities so that the cost of intensive care is not a deterrent to making organs available. The Government must also take action to ensure that there are enough nurses and medical staff so that the removal of organs can take place. Obviously, I should like to see an expansion and development of research into the matter. It is the responsibility of the Government of the day to provide the basis for medical advance and lay the groundwork for breakthroughs in future.

Transplantation is a difficult matter, surrounded as it is with fears about spare parts surgery. When I asked myself whether I would be prepared to have my organs used after my death, without any hesitation and difficulty I said yes. I have carried a donor card for years. I have absolutely no difficulty about that. My husband, who comes from a Catholic background, is certainly against the cremation of his body. He has a different approach, but he automatically said yes, he would be prepared for any of his organs to be used for transplantation after his death.

We asked ourselves whether, if one of our children suddenly died, we would be prepared to allow their organs to be used for transplantation. We paused and felt that sense of horror that parents obviously feel when they think about their child's organs being taken out of their dead body and donated. For a few seconds, we imagined ourselves in the shoes of the parents of a desperately ill child who needed a transplant. It is easy to understand why the required-request system must be introduced. Our answer to the request would be yes. We must always recognise that there is a sense of contradiction. We must be on the side of those who have the possibility of life, and we must make that possibility a reality by ensuring that organs are available.

The hon. Member for Cardiff, North has a great deal of support for his motion. He has the support of many hon. Members who are not able to be here today but have asked me to convey to him their support. They are concerned that the Government should take action. In particular, my hon. Friend the Member for Linlithgow (Mr. Dalyell) is not able to be here, but I can say that he fully supports the points that were made by the hon. Member for Cardiff, North. I support the endeavours of the hon. Gentleman and hope that the Government will respond positively and take action where it is needed.

10.23 am
Mr. Michael Shersby (Uxbridge)

I congratulate my hon. Friend the Member for Cardiff, North (Mr. Jones) on his good fortune in the ballot and on choosing the important matter of transplant notification procedures as the subject of debate. I am pleased to support his motion.

My interest in this subject arises from the fact that one of the country's principal centres of excellence in heart and heart-lung transplantation is Harefield hospital, which is situated in my constituency. As a result, I have a close, ongoing relationship with Professor Magdi Yacoub and his team, and take a close interest in the availability of donor organs and the advancement of transplant surgery generally. The only real limitation on the number of transplants that are carried out at Harefield is the availability of donor hearts. The clinical criteria for carrying out transplants are widening as the success of operations becomes more clearly demonstrated.

In 1987, 180 transplants were carried out at Harefield. A total of 550 transplants have been carried out there. The longest survivor is now eight and a half years on from a transplant operation. There is an 80 per cent. survival rate at two years, as against the possibility that all patients would have died within six months had no transplants been carried out. Of the 550 transplant operations, some 250 have been carried out during the past two years. Now, unlike other operations, there is almost complete certainty that patients would have died had no donor hearts been available.

In the current year, Harefield has about £3.1 million to carry out 180 transplants under the National Health Service. That sum includes an additional £740,000, which has just been allocated by North West Thames regional health authority. I pay tribute to the North West Thames regional health authority for the wonderful support that it has always given the transplantation programme at Harefield. The regional health authority and the Hillingdon district health authority have ensured that it is now one of the premier centres of excellence. As evidence of that, the expansion of the National Health Service and the improvement in patient care, only last Thursday Her Royal Highness the Duchess of York opened the new intensive therapy unit at Harefield, which is now providing excellent care for transplantees. The unit cost about £1.4 million. It is yet another example of new NHS facilities being opened and of the way in which the taxpayer is receiving better health care.

The unit looks after adult cardiac and thoracic surgical patients and adult patients who are recovering from heart or heart-lung transplants. It contains a range of highly sophisticated monitoring and life support systems. Alongside it is the new Eric Morecambe department of cardiology, named after the comedian whom we all knew and loved so well and who benefited from cardiac surgery. The building costs were paid by the generous support of the Sportsman's Aid Society, and the furniture and fitting were paid for by the hospital league of friends. I pay tribute to their generosity. I hope that my hon. Friend the Member for Cardiff, North will not mind referring to those matters in passing.

All the facilities and the substantial available funds can be deployed to maximum effect only if more donor hearts are available. The Hoffenburg report attempts to discuss the present position of organ donation and the reasons for the shortfall in donations. It makes a valuable contribution to a better understanding of the main problems facing doctors and the problems of relatives of deceased persons whose organs are needed for transplants. The report sets out to reassure the public about the criteria to be adopted before organs are removed. It is clear, reassuring and helpful on brain stem death.

As my hon. Friends, the Members for Cardiff, North and for Wycombe (Mr. Whitney) and the hon. Member for Peckham (Ms. Harman) pointed out, the report rejects the concept of legally required request—a concept that has now been adopted in 30 states of the United States of America — whereby a hospital administrator or his assignee should ask a deceased person's relatives for the gift of organs.

As my hon. Friend has said, the option of an effective audit is, in the opinion of the working party, preferable to the legally required-request procedure. My hon. Friend has pointed to all the difficulties that that would present in the future and he is not optimistic that it would lead to an increase in the supply of donor organs. I must agree with him. I am sure it will mean a continuing shortage of donor organs and a continuing waiting list for those patients for whom a transplant is the only hope of life.

I think that I can understand why the report reached that conclusion. No doubt, among the many other matters that they considered, the members of the working party had in mind the distress to relatives of those who have suffered sudden death. However, I wonder whether they took account of the feelings that relatives expressed in "That's Life." They made it clear that if they had been asked to agree to the donation of the organs of their deceased relatives, they would have done so, and that today they would have felt a great sense of comfort that the organs of their loved ones were making it possible for another person to live a normal, happy and healthy life.

The hon. Member for Peckham made what I thought was a good suggestion; namely, that research should be initiated by the Under-Secretary of State for Health and Social Security, my hon. Friend the Member for Derbyshire, South (Mrs. Currie), and her Department into the attitudes of bereaved relatives. We need to know more on that subject. We need to know the views of those people who have suffered bereavement.

If the concept of required-request is not to be adopted, what is the alternative? Indeed, is there a reasonable alternative that would lead to an increase in the supply of donor organs? I believe that there is only one realistic alternative and only one other way forward: to secure the support of the public, and especially of young people, for carrying donor cards or, even better, some other form of a much more permanent indication of their willingness, or otherwise, to donate their organs.

Yesterday two young women work-shadowed me in the House of Commons. They came from Bishopshalt and Swakeleys schools in my constituency. Last night we discussed this debate and I asked them about their attitudes towards the donation of organs. I was proud to find that both those young women carried donor cards. One of them had obtained her card from a chemist and the other one had seen the cards in a doctor's surgery and collected her card from there. The only realistic way forward is to ensure that the vast majority of people are persuaded to carry a donor card, especially young people.

One nasty aspect of this whole business is that often in serious accidents the donor card is separated from the individual who has suffered the accident, and it is not found until too much time has elapsed to remove an organ. We need to find other ways to signify an individual's agreement to donate organs. The report talks about the possibility of agreement, or otherwise, being shown on a driving licence. Another possibility would be that each individual who holds a driving licence should be entitled to notify the Driver and Vehicle Licensing Centre of their wishes and that that information should be kept on the DVLC computer. Another way of handling this matter might be to encourage the wearing of what in world war 2 were called "dog tags"; in other words, a simple and elegant chain around the neck, perhaps with a small plate bearing one's name and an indication of one's wishes.

In addition to those identification procedures, I believe that there is another way of tackling the problem. I urge my hon. Friend the Under-Secretary of State to discuss with her right hon. Friend the Secretary of State for Education and Science the carrying out of a sustained education programme in our schools.

Public opinion on this matter is most likely to change if people make the decision themselves. Young people are far less apprehensive about such matters than their parents. They have grown up in an era when heart and heart-lung transplantation is almost an every-day occurrence. They believe in it and are proud of it and in many cases want to support it. That presents an alternative way forward to required-request. We should secure the voluntary support of the public, and especially of young people.

I welcome the motion most warmly. It is important. It could well be that in the next year many people who receive heart or heart and lung transplants will have cause to be grateful to my hon. Friend the Member for Cardiff, North for drawing attention to these matters. He may have succeeded in taking a major step forward in encouraging many people to indicate their wishes now and thus make more organs available.

There is no doubt that in the years to come major advances will be made in cardiac surgery of every kind. It could well be that within a decade or more we shall no longer have to rely on the transplantation of human organs, and that it will be possible to substitute for them artificial organs of some kind. Although we have not yet reached that stage, I have no doubt that it will come. Until it does, I have no doubt that we need to secure the support of the population of this country to donate organs to make it possible for other people to live.

10.36 am
Mr. David Wilshire (Spelthorne)

I thank my lion. Friend the Member for Cardiff, North (Mr. Jones) for giving all of us who feel strongly about this subject the chance to join the debate. The part of the motion about which I wish to speak relates to identifying donors and obtaining organs. However, having heard the discussion about required request, I am prompted into saying something further about that.

The reason I want to join the debate is that I can speak from direct personal experience. It is important that those of us with such experience join in, because far too often any discussion of these issues is either academic-led or medical-led. I believe that those of us who have been through the mill ought to speak up; we have something to contribute.

Six and a half years ago our daughter choked to death at school. She was taken to hospital and my wife and I rushed there. To this day. I can remember every awful detail of what followed. We were surrounded by enormous help and a huge amount of support so what I want to say implies no criticism of anybody. However, no use was made of any part of Sarah's body. No thought was given to it by us, and it was not mentioned to us by anybody else.

Six and a half years later the dust has settled a bit and it is possible to think positively and constructively about what we went through. Sharing that sort of experience may well help people to come to some sort of conclusion of their own, and it may help us to nudge people towards thinking about it for themselves. Indeed, it may nudge the medical profession into plucking up the courage to ask more often. I use the word "nudge" and will talk about "encourage" deliberately, because I am against compulsion. I am against legislation trying to force anything in this sensitive area.

That experience taught me and my wife three things. Our first conclusion was that a great deal more could be done to encourage people to think about these nasty issues when there is no crisis. We had long since carried kidney donor cards, but if only, when there was no crisis, somebody had encouraged us to think about the unthinkable—our children's possible death—we could have done something then. We would have mocked and said, "Of course we do not need to think about our children's death", but in our case circumstances proved otherwise.

Our second conclusion is that some thought needs to be given to what happens when people have been encouraged to do something for themselves. I have a feeling that no one in the NHS or anywhere else knows that I carry a kidney donor card. The chances are that if I turn up when someone is interested in knowing whether I have a card I shall be in no position to tell that person, and there is a good chance that I shall turn up without my wallet. If someone said to me, "Here is a computer-based register. Would you like to put your name on it?" I should be the first to volunteer.

The third conclusion that I reached was that ways must be found of asking distraught relatives whether they are willing to help. Much has been said about required request. My experience teaches me several things. Any suggestion of the right to remove must be resisted at all costs. Any suggestion that distraught relatives have to go through some sort of system of opting out must be resisted. Compulsory asking is far too insensitive a way to deal with an issue that is complex and needs to be handled in a different way. I realise that what I am saying means that there will probably be fewer organs available than if we went down the road of compulsion. My experience taught me. Although I regret that I was not asked, I cannot bring myself to accept that compulsion in that circumstance would help.

The problem is that someone must do something and it has to be done at the worst possible time. It is in the moments after an unexpected bereavement that the question must be asked. Time is of the essence and, sadly, accident victims are often the best source of organs. If progress is to be made, the asking process must be made natural and normal. Whatever we decide to do, we must all accept that there will always be a risk of hurting people when one asks. Sometimes, one will even outrage people, but, looking back, I wish that someone had asked me.

How should we get the question asked? Perhaps training could be given — this has been mentioned several times in the debate—to all hospital staff in how to decide for themselves whether the bereaved people with whom they are dealing are the sort whom they should ask, and training could also be given in how to ask. Perhaps my hon. Friend the Minister will consider whether district health authorities and family practitioner committees could be encouraged to develop local guidelines on how to set up some sort of system for getting the question asked more often.

Perhaps people such as myself who have been through this mill and know, although we are laymen, exactly what we are talking about, could somehow be encouraged to volunteer and the hospitals be asked to keep a list or register of those whom they could telephone asking them urgently to come and talk to people going through what others had been through before. I stress that it must be encouraged request, not required request.

If we are to make progress, as my hon. Friend the Member for Cardiff, North wishes, it will come from identifying donors and obtaining organs rather than from anything else. Looking back on what happened to me, I believe that we must encourage people to think the unthinkable. We must persuade them to offer parts of their own bodies and, when they are least able to think about these matters, to agree that parts of their relatives' bodies can be made available as well.

If my personal experience teaches me anything, and if that experience is of any help to other people, I sum it up like this: I wish that I had been asked and, as I said earlier, I mean no criticism of anyone that I was not, because I could always have said no. Because I was incapable of thinking clearly at the time and because no one asked me, no part of my dear daughter's body has ever been able to help anyone.

10.44 am
The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)

I congratulate my hon. Friend the Member for Cardiff, North (Mr. Jones) on his success in the ballot and on again giving us an opportunity to debate this important subject. His speech was not only interesting and extremely well researched but a major contribution to the debates and thinking on these topics.

I thank also my hon. Friends the Members for Wycombe (Mr. Whitney), for Uxbridge (Mr. Shersby) and for Spelthorne (Mr. Wilshire) and the hon. Member for Peckham (Ms. Harman) for their speeches. I was deeply moved by the speech of my hon. Friend the Member for Spelthorne. I was going to read out some letters from parents whose children had died and who had been unable to make a donation of that kind, but my hon. Friend's comments have made that unnecessary. I hope that his words will move the nation as they have moved me.

As part of my research for this debate, I read through some old Hansards on the subject. It was a fascinating exercise for anyone interested in how attitudes have changed in this tricky subject, and I recommend it. If one goes back to 20 December 1960 and the debate on the Second Reading of the Human Tissue Bill, we find Mr. Kenneth Robinson, then the Opposition spokesman on health, telling the House: About ten years ago I was approached by certain members of the medical profession about the difficulties of getting sufficient corneas for grafting. I spoke to the then Minister of Health and asked whether there was anything I could do by way of publicity and Parliamentary Questions. The right hon. Gentleman went away and, having seen his advisers, came back and said to me, 'For heaven's sake do not raise this matter. Corneal grafting is going on, but the moment we give it any publicity there will be religious objections and the whole matter may come to an end. So please leave it alone.'" —[Official Report. 20 December 1960; Vol. 632, c. 1235.] The thought that these days anyone would have strong religious objections to corneal transplants probably seems preposterous to us, and the thought that these days any Minister of Health might want to discourage progress is, I hope, also preposterous.

The Human Tissue Bill was not the first legislation on this subject, for it replaced and augmented the Corneal Grafting Act 1952 which, in turn, augmented the Anatomy Act 1832, which was the first legislation on this subject, and parts of which are still extant. To look back on all that was an interesting exercise. There were ten-minute Bills, one after the other, in the 1960s and 1970s, many at the instigation of the hon. Member for Linlithgow (Mr. Dalyell). There was the statement in the House 20 years ago, almost to the week, again by Mr. Kenneth Robinson following Britain's first heart transplant.

The House, in the shape of its Back-Bench Members, has an outstanding record in raising this important issue, but some features have struck me forcefully. First, there has always been much public support for the transplant programme. The British public has always been interested in the subject and very supportive. Outright opposition has always been confined to relatively few people among the lay public. Secondly, one of the key necessary changes has had to come in attitudes to death. I noted with interest the words of Norman St. John-Stevas, now Lord St. John of Fawsley, in the debate in February 1969, in which he said firmly: death is the final and irreversible cessation of perceptible heartbeat and respiration."—[Official Report, 26 February 1969; Vol. 778, e. 1739.] Twenty years on I think that it is now generally accepted that brain-stem death is the appropriate criterion. Legislation in other countries copies our codes on brain-stem death, which have been in operation here for some time.

The third feature which is obvious to anyone who looks back into this subject is that the surgery is technically much trickier than anyone expected. The first 100 or so kidney transplant patients all died and the first heart transplant patients never left hospital. For many years, the success of kidney transplantation was below 50 per cent. Only recently have many of the technical difficulties been overcome, with increased attention to the removal of the organ, so that it is not damaged, and to the insertion in the patient requiring the transplant and with the advent of cyclosporin and other drugs, which have been an immense help in preventing rejection. This is now one of our most, rather than least, successful forms of surgery.

The fourth thing that struck me was that there were never enough organs. There never have been enough organs and I suspect that there may never be enough organs. When Lord Ennals stood at the Dispatch Box and some 700 kidney transplants a year were being done, the waiting list was 1,200. We could now cover that in about eight months in any particular year. However, I suspect that our waiting list now, to which attention has been drawn, suggests that there is possibly no natural limit to what could be done in this area.

Far more people are now on dialysis, and the advent of continuous ambulatory peritoneal dialysis, which is particularly helpful to diabetics and to the elderly, has shown that many people can be kept alive for longer and many more people can benefit. One might speculate that in future the transplantation of heart or kidney might be as commonplace as putting in a heart pacemaker. With the improvement in anaesthesics that is now occurring, it may well be done in future under a local anaesthetic. One can see that by the beginning of the next century, in other words another 20 years on, the debate may take much the same form about not enough organs as now.

Yet what has become apparent in all the years during which this has been discussed is that the operation is never commonplace and never can be. It is not commonplace for the recipient for in many cases we are talking about people who face death quickly or, if not death, many years of misery on dialysis. It is never commonplace for the donor, the family or the staff concerned. My experience goes back to the early 1980s when I was the chairman of the Central Birmingham health authority. I can well remember walking into the Queen Elizabeth hospital one day to find the place abuzz. When I asked what was going on, they looked at me and said, "If you find out, chairman, you will stop it." I had to promise that I would not interfere before they would tell me that Mr. McMasters was going to do a liver transplant that afternoon. Everybody knew about it and was excited and apprehensive.

It is worth bearing in mind that the staff are also affected by this. The lady concerned needed 42 pints of whole blood, the entire laboratory was up for many nights testing her every 15 minutes. The intensive therapy department was completely tied up looking after her and a large number of other operations had to be cancelled. Everyone was excited that it should happen and devastated when, despite the fact that the operation was successful, the patient died. We must bear in mind that all our staff, not just the doctors, are greatly affected by this event.

Our record on organ transplantation of all kinds is excellent and all those concerned can take pride in it. We have more patients with a functioning kidney graft than any other country in Europe—about 7,000 people. In 1986, the most recent year for which we have comparable figures, we were the leaders in Europe, together with the Federal Republic of Germany, in the total number of kidney transplants performed. We think that it managed two more than we did. For transplants using cadaveric donors, we were clearly in the lead with some 1,500 compared with about 1,200 in West Germany. No other country in Europe had over 1,000 in that year, although many are now increasing their transplantation programmes rapidly.

Our heart-lung and liver transplant programmes are probably the most successful in Europe, and have expanded year by year in the 1980s as the operation has become technically much more successful. I apologise to the hon. Member for Peckham. I mean absolutely no criticism of anyone before 1979, but the figures I have are only for the period under this Government. In 1979, we performed 842 cadaveric kidney transplantations in the United Kingdom; the provisional figure for last year is 1,479. That is a total increase of some 76 per cent. In 1979, we did three heart transplants; last year, we did 244. We did no heart-lung or liver transplants in 1979, but last year we did 72 heart-lungs and 170 liver transplantations. There are no longer any accurate statistics on corneal grafts because it is now routine, but we believe that between 1,500 and 2,000 such transplants take place every year.

The survival rate of the transplants is improving all the time. In 1982, only about 50 to 60 per cent. of patients with a heart transplant were surviving for a year; now it is about 80 per cent. From 1977 to 1983, about 40 per cent. of liver transplant patients survived for a year; by 1985, the proportion was about 70 per cent. and it is rising. In 1980, some 61 per cent. of patients with kidney transplants still had that kidney functioning after a year; in 1985, the figure was 77 per cent. This is encouraging, but it puts even more pressure on us to increase the number of organs available for transplantation. As all hon. Members have said today, large numbers of people still die in circumstances which could make them suitable donors but where donation is not even considered.

The operations are not only successful, but getting cheaper. I noted with interest a report from Dr. John Wallwork, the consultant cardiac surgeon at Papworth hospital in Cambridge, in The Daily Telegraph of 19 February 1988. The newspaper said of heart-lung operations: The operation, which takes between 2½ to six hours, used to cost £22,000, including hospital care for 12 months post-operatively, With advances in treatment which allow the patient to return home after three weeks—half the time initially allowed—the cost has dropped to £15,000. Kidney transplants now cost us about £8,000 and about £2,500 in following years. If someone has a good job, they probably pay more than that in tax, and that point has been well made.

Mr. Shersby

My hon. Friend has said that the cost of a heart-lung transplant is about £15,000. Does she agree that the cost of a heart transplant is substantially less than that?

Mrs. Currie

My hon. Friend is ahead of me slightly. To finish the comparison for kidneys, a kidney transplant costs £8,000 haemodialysis varies between £12,000 and £15,000 and CAPD varies between £8,000 and £10,000. That is based on a 1982–83 study, but uprated to current prices. It shows how much a kidney graft is entirely cost-effective, especially considering the high success rate that I have mentioned.

A heart transplant costs £12,000 at current prices and a liver transplant £18,000 on current prices for an adult and £25,000 for a child. We must reflect that, since the alternative is almost certain death and in many cases these people can be returned to normal life — indeed, for children a lifetime of normal life — they are a bargain and value for money. On that basis alone, we should continue to pursue them.

I mentioned that our success on transplantation has been helped by a considerable measure of public support. The most recent survey that I have been able to lay hands on was that by the British Kidney Patient Association which commissioned a survey by Gallup, published in January 1987. It shows that 68 per cent. of all those questioned said that they would agree that their kidneys could be used after death for transplant purposes and 66 per cent. said that their hearts could be used. That was at a time of considerable controversy about this topic. Twenty years ago the figure was roughly the same, about 70 per cent.

Our approach to organ donation is that it should be voluntary, that the rights of individuals must be protected and that the education of the public is vital. That is the basis on which we have the most successful programme in Europe. Public education — I have heard many good ideas about it today — has been focused on repeated campaigns through poster displays and advertisements on television, in doctors' surgeries, in banks and many other places. These usually involve the distribution of our donor cards.

While I accept many of the criticisms that have been made about the donor card scheme, we emphasise that all those who carry a donor card should discuss their wishes with their families so that, even if the card is not found, the family of the potential organ donor will know what that person would have wanted. We must also get across the message that families do not have to wait to be asked. They can, should and do let the doctors know the wishes of their loved ones. We have co-operated with commercial organisations, sportsmen, entertainers and other well-known people, and at present British Telecom is helping us by including cards with telephone bills sent to customers in the London area. We are grateful for that help. At present some 5.5 million donor cards are in issue.

We are in no doubt that publicity has a direct effect on the number of donor organs becoming available, but it can go both ways. A "Panorama" programme in 1980 gave the public a bad impression of organ donation and the number of kidney transplants dropped by over 8 per cent. in the following year. In 1984, Esther Rantzen publicised the case of Ben Hardwick who needed a liver transplant, and when we renewed the donor campaign the number of kidney transplants increased by 26 per cent. Therefore, many other children owe their lives to Ben's circumstances.

In December 1986, a series of newspaper stories suggested that people diagnosed as brain-stem dead were not actually dead and was followed almost immediately by a fall in donated kidneys. That explains why the 1987 kidney transplant total is marginally down on the record 1986 figure. But I was able to take part in the "Gift of Life" programme on 10 January this year, and again the figures have turned upwards dramatically. I pay tribute to Esther Rantzen and the team from "That's Life" for the efforts that they have made. They do not know the figures that I am about to read out, which are a tribute to their work.

I examined the figures for the number of transplants reported to the United Kingdom transplant service in the four weeks following the "Gift of Life" programme and compared them with an exactly equivalent period at the beginning of 1987. At the beginning of 1987, we did 72 kidney transplants. At the beginning of 1988, we did 138, which is almost double. At the beginning of 1987 we did 83 cornea transplants. We think that we did 143 at the beginning of this year, although, as I said, the figures for corneas are a little uncertain and are almost certainly higher than that.

At the beginning of 1987, we did 12 heart transplants. This year, the figure was 21. We did no heart-lung transplants at the beginning of 1987. In the first four weeks of this year, we did 13. In 1987, we did nine liver transplants. This year, we did 17. In the four weeks from 10 January to 6 February 1987, the lives of 21 people were saved by heart, heart-lung and liver transplants. In the four weeks from 9 January to 5 February this year, 51 lives were saved. All those people will join me in expressing thanks to Esther Rantzen and her team. I met her recently at the Woman of the Year lunch held by Woman's Own magazine, and I was delighted that she was chosen Woman of the Year by the readers of that magazine. That was well deserved.

There is still much more to be done, but we believe that a considerable impact has been made in the education of the general public. We are less happy about the attempts to make professional staff in the Health Service more aware of the need for donation. It is clear that more cadaver organs would become available if more relatives of potential donors were approached about the possibility of donation. In that I agree completely with everything that my hon. Friend the Member for Cardiff, North and other hon. Members have said. Although it can be distressing at a very sad time, it can also provide an opportunity for something good to come out of a tragedy.

My hon. Friend the Member for Wycombe said that he had visited the United States to see what had been done on required request. After his visit, we approached the medical royal colleges and asked them to recommend how we might proceed on the subject. They have told us that hospitals should have clearly defined procedures for identifying potential donors and for referring them to the appropriate transplant unit or co-ordinator.

We do not know how many organs there are that might be suitable for transplants, nor do we know why those organs are not made available. There are many possible reasons. Staff may be unaware of the need for organs. They may be unwilling to approach relatives at a difficult time. The relatives may be unwilling to agree, even though they know that the deceased person would have wanted his organs to be used. In many cases, doctors are unlikely, or feel unable, to proceed because of the distress that they or the relatives may feel.

There may be different problems. For example, if there is pressure on intensive care facilities, it will not always be possible to use them to maintain a donor in a suitable condition until organs can be removed if another patient's life could be saved by using the facilities. Because we do not know the relative importance of the possible reasons, we agree with Sir Raymond Hoffenberg's working party that there is a need for an audit of cases where organ donation is a possibility. My hon. Friend the Member for Cardiff, North asked how we are getting on with that. I have in front of me an outline of a draft circular that has not yet gone beyond the word processor stage. We intend to issue a draft circular soon to the health authorities. We shall then have the usual three-month consultation period, as we do on draft circulars, and we expect to issue the circular proper later this year.

Some district health authorities have already started to audit brain-stem deaths. I understand that audits are being conducted in Cambridge and Brighton, and there may be others. It is interesting to think about the headings that may be contained in such a draft circular. For example, as my hon. Friend said, we shall ask health authorities to ensure that hospitals in which potential organ donation is likely to arise have written procedures for the identification of potential organ donors and for notification of the appropriate transplant staff. We shall ask authorities to record all instances of brain-stem death, collecting information that will be set out clearly in the circular, and reporting the results to the Department.

I take seriously the points that have been made about training, and we shall give careful thought to the matter. We are after two things: first, consistent information; and, secondly, the creation of structures within health authorities and within each hospital involving all the staff concerned. By the very means of collecting the information, those structures will he set up. I am confident that that will have a beneficial effect. It will force every doctor to consider whether a person who has died offers the opportunity for donation. It will also force doctors to consider their attitudes to the matter and to record precisely what they propose to do. The information to be reported from the audit of each case of brain-stem death will show whether the transplant co-ordinator was notified and, if not, the reason—the age of the donor, infection, malignant disease, unstable circulation, relatives not approached, relatives refused and other items. We are giving serious and urgent thought to whether we should collect more information than that, although I am conscious that in the United States one aspect of the required request programme that produced complaints from medical staff was the number of forms that had to be filled in. That put some of them off.

We have taken seriously the work that has been done on required request in the United States, and my hon. Friend is not alone in believing that we should follow the American pattern and require hospital staff by law to ask relatives for permission to take organs. The medical royal colleges have advised against that, and I understand why. Apart from anything else, and despite the fact that we have had legislation for nearly 30 years, the United Kingdom programme has not been based as much on the law as it is in other countries, especially the United States, and we would not lightly change that.

I have gone into the matter in some detail and I put on record our thanks to the United States authorities, especially those in New York state, with whom we are in close touch. I have many documents from America, including some that were sent to us only a couple of weeks ago. During the past two years, 30 American states have passed laws requiring hospitals to request organs or to develop procedures for doing so when a clinically suitable patient dies. From 1 October 1987, a federal law took effect establishing a national system for organ sharing, which we already have, and stating that hospitals should not participate in Medicare or Medicaid unless they developed written protocols for the identification of organ donors. That is precisely what we intend to do following the Hoffenberg report.

As yet, there has been no reliable or even regular collection of data on the effect of the laws introduced in the United States. It is important to put on record the fact that there is only anecdotal feedback. Indeed, there is little on which we can draw. Few articles have been written. I have read all of them, and they have not yet convinced me to change my mind. An article by Tolle and others in the "Annals of internal Medicine 1987" pointed out that Stanford university medical centre had experienced a 38 per cent. increase in heart and heart-lung donations since implementation of the law in California. An article by Kayali in "Dialysis and Transplantation 1986" said that in New York donations had increased by 48 per cent. and corneal donations by 160 per cent. since the advent of required request laws. We have also received a communication from Oregon showing that corneal donations there have increased by 134 per cent. since the introduction of the laws.

I am going into this in some detail because this is my best opportunity to respond to my hon. Friend the Member for Cardiff, North and to say why our thinking does not entirely go along the lines that he advocated, although I do not disagree with him entirely, as he knows. The first interesting factor is that the number of transplants in the United States is increasing steadily anyway, and some of the change that has been attributed to required request legislation might have happened without it. For example, the number of liver transplantations since 1982 has been doubling every year. In 1981, there were 26 liver transplantations, and there were over 60 the following year, over 160 the year after, over 300 the year after that, and over 600 in 1985. Therefore, the rate of growth has been fast.

The rate of growth of the number of heart transplantations in the United States has also been doubling every year; there has been a substantial increase. The rate of growth of kidney donations went up by between 10 and 15 per cent. every year before the required request law.

When we look in detail at what is happening in New York—my most recent communication from New York was on 15 January this year — we find that, unfortunately, despite the fact that detailed figures on organ procurement were collected in the first 17 months after the introduction of the law, we do not yet have a clear answer. Between 1985 and 1986, the number of organ donors was rising. In 1987, the number of donors dropped. The number of organs procured changed in ways that were not entirely consistent. For example, the number of hearts went down, the number of livers went up, and the number of kidneys seemed to be fairly static. That suggests a different pattern of harvesting from the donors who become available. It does not suggest an increased number of donors. In this country, that is one of the things that we should be keen to get at. The increase in organ donors in 1986 was not maintained in the first months of 1987.

It follows that required request might not have been an unqualified success. Again, personal communications from New York show that the variation, which seems to be diverse across the different centres in New York, seems to be a function of the personalities and attitudes at different hospitals. Part of the problem in places such as New York are rising worries about AIDS and that in the past a large proportion—as much as 20 per cent.—of the programme has been based on living donors. New York is trying to shift that emphasis.

A report to the governor and the legislature in 1987 from the New York state Department of Health contains a sentence that struck me: It was frequently observed by surveyors that success in organ and tissue retrieval was largely the result of a strong commitment by key medical staff, supported by clear direction from administration and programme coordinators. We are after exactly the same thing. We are convinced that, by the implementation of the Hoffenberg report, we can have the essential ingredients of the success that seems to have been developed through the required request legislation. But perhaps we can make it much more consistent across this country, which already has such a strong record and history in organ donation.

I give my hon. Friend the hon. Member for Cardiff, North and everyone in the House this firm pledge. I have given it on television and it is probably appropriate that I give it in the House now. If the Hoffenberg system does not work and does not produce what we want, we shall consider it again, but I suspect that among the other things that it will produce will be a lot of evidence about what actually happens in our hospitals, which will assist us if we feel obliged to persuade the House in future that legislation is required.

Ms. Harman

Will the hon. Lady set a particular period within which she expects the Hoffenberg proposals to work? Although she is refusing required request, those of us who favour it would be much reassured if she said that the Government would give the proposals four years to work and that, if they did not, we should have required request. Will she give us that guarantee, even if she does not accept required request now, as we should like her to?

Mrs. Currie

I am sure that the hon. Lady will understand that I cannot give absolute views on that, because a successor of mine might have to act on the results. Our present view is this. We expect that the circular will be out before the end of the year. I hope that we can get everybody started on it — I should prefer a fixed date, such as 1 January. We are considering and taking advice on that. I hope that the bulk of the hospitals that might be involved in the programme will be by the beginning of next year—in other words, by this time next year. It will be at least 12 months before we have any consistent figures.

Apart from anything else, the accident patterns in this country have seasonable fluctuations. I think that it would be wise at least to give the system another year after that before any firm conclusions were drawn. In other words, we are talking about around 1990 before it would be wise to draw up any strong conclusions about whether the programme has worked. It seems sensible to do so.

Meanwhile—let me make this point once more—as the system is introduced, the essential ingredients of what the Department of Health in New York state feels to be the working in parts, the effective parts, of its system will be brought in this country. We hope that, by voluntary means, as several of my hon. Friends have said, particularly my hon. Friend the Member for Spelthorne, we can achieve the success rates that are anticipated and hoped for by everybody concerned.

No one would expect me to stand at the Dispatch Box without saying something about prevention. One of the things that struck me as I went back through 30 years of debates was that nobody asked questions about how we prevent end-stage kidney failure, which leads people to need the donations in the first place. Therefore, I asked for some professional advice and I should like to offer the House this information.

I am told that the commonest cause of end-stage kidney failure, which is glomerulonephritis, cannot be prevented, but control of hypertension, which often accompanies that disease, can slow the progression to give the failure. I am advised that the role of raised blood pressure in the development of kidney damage is twofold. First, high blood pressure per se, particularly in its most severe forms, can cause kidney damage and renal failure. Hypertension by itself accounts for some 10 per cent. of all cases of end-stage renal failure. Control of hypertension has already succeeded in halving the number of cases proceeding to kidney failure. It is therefore absolutely essential for anyone who is interested in the organ donation programme, particularly kidney donation, to take into account the fact that high blood pressure is a key factor.

That is one of the items that we are taking into account as we develop our reforms of primary care. We are particularly keen that general practitioners should know and be able to take cognisance of the fact that kidney failure and high blood pressure are associated, particularly in ethnic minority populations, in which hypertension is more severe and damaging. There is also concern about certain drugs and the effect that they can have on kidneys. Those matters are kept under constant review by the Committee on Safety of Medicines.

I am also aware that many children suffer from kidney failure. I understand that the role of urinary tract infections causing kidney failure has been greatly clarified in recent years. All the research points to the fact that damage to the kidneys is done in young children when infection and vesicureteric reflux—otherwise known as VUR—coexists. VUR is a condition in which the urine goes the wrong way—it goes up to the kidney. It is usually due to an inborn malformation, which can be detected by ultrasound screening. The value of such ultrasound screening in the prevention of kidney scarring is now being studied in Cardiff, thanks to the generous support of the Laura Ashley Foundation. That also suggests that infections should be controlled in children, or they can cause permanent damage, particularly later.

The principal inherited disorder often found in children is polycystic disease of the kidneys. It is now possible to detect that condition in utero. But there is a certain amount of difficulty in recommending therapeutic termination, for many patients with polycystic disease live to a ripe old age, particularly if a rise in blood pressure is detected and controlled. Strict control of diet is also an important and valuable factor, particularly in the postponement of end-stage renal failure, when the kidneys are weakening. Research is being done on that in various centres.

I should like to conclude by making two important points. We must have the support of the public in this area of work. We cannot go faster than public opinion, but I am reassured by the remarkable interest and the remarkably consistent support that they have demonstrated through opinion polls and in other ways. We must have the support and understanding of the medical profession and all the staff concerned, for that work will always demand the highest standards of technique, which is why we limit the number of centres where we can do the work, because nothing succeeds like success, particularly with the medical profession.

It is also a matter of ethics. The programme is based ultimately on trust. Those are the absolute necessities. We believe that the cautious, methodical and detailed approach recommended by the Hoffenberg committee will achieve those results and thus help us to secure the programme in future. I have taken careful note of all the points made and I am glad to repeat my pledge that if we do not make progress this way, we will give the matter further consideration.

11.20 am
Mr. Gwilym Jones

We have had a worthwhile debate on this important subject. Friday is not the easiest day for debates. As the hon. Member for Peckham (Ms. Harman) said, right hon. and hon. Members who would have wished to be here have been unable to take part because of the commitments that we all try to juggle, and because Friday is a popular day to he in our constituencies.

The debate has focused attention on this subject, and I am grateful to the hon. Member for Peckham, to my hon. Friend the Member for Wycombe (Mr. Whitney), who was kind enough to be one of the sponsors of my Transplant Notification Bill, and to my hon. Friend the Member for Uxbridge (Mr. Shersby), who has had to leave for a constituency engagement, as has my hon. Friend the Member for Wycombe, who has an obvious constituency interest in the form of Harefield hospital.

As my hon. Friend the Under-Secretary of State said, we were all most moved by the speech made by my hon. Friend the Member for Spelthorne (Mr. Wilshire), whose personal experience is most apposite to this emotional subject. I cannot applaud highly enough his speaking out. We need his contribution to this subject. He takes a slightly different approach from me, but it is clear that we all want to achieve the same objective. There is plenty of opportunity for constructive debate about how we reach that objective.

I join my hon. Friend the Minister in applauding the BBC television programme "That's Life" on "Gift of Life", which was shown on the first Sunday in January. All the publicity has been rewarded by a doubling in the number of transplants performed. We had an excellent response from my hon. Friend the Minister. One of the greatest values of these debates is hearing a ministerial contribution. My hon. Friend has done a valuable service to the future consideration of this subject with her well-considered speech. What she said will be considered widely. I was pleased to learn that there is a draft circular on the word processor, and I hope that it will be in place by 1 January.

I am sure that my hon. Friend the Minister will continue to consider cost and the recommendations of the Hoffenberg report — reimbursing district health authorities for the cost of removing organs. My hon. Friend talked about the required request experience in the United States. She said that much of what is said to have happened as a result of it might have happened anyway. The other approach is that the success of medical advance breeds demand. The more successful transplants are, the more people will be encouraged to add their names to the waiting list. There is no point in queuing for operations that are not available, but many techniques have been devised only recently. We shall have to run faster merely to stand still. My hon. Friend mentioned a waiting list of 1,200 some years ago. That could now be dealt with by eight months of operations.

I regret that my hon. Friend the Minister is not in full agreement with me, but I know that she will continue to give the matter deep consideration. I appreciate the pledge that she gave on the "Gift of Life" television programme, which she has now repeated in the Chamber. I have hopes of the consideration that she will give the matter and of the progress that we shall make.

Question put and agreed to. Resolved, That this House welcomes recent advances in transplant technology and in the availability of transplant operations through the National Health Service; especially welcomes the Government's commitment to secure further progress in this vital area; notes that the recently published Hoffenberg Report recommends steps to improve the supply of donor organs; recognises that it is the shortage of suitable organs satisfactory for donation that limits people's opportunities to enjoy a greatly enhanced quality of life; and calls for action to be taken to achieve further improvements by more effective procedures which, whilst being sensitive to the needs of patients, relatives, the bereaved, doctors and other health professionals, effectively identify potential donors and increase the availability of donor organs.

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