HL Deb 20 July 1988 vol 499 cc1389-95

7.38 p.m.

The Parliamentary Under-Secretary of State, Northern Ireland Office (Lord Lyell) rose to move, That the draft order laid before the House on 28th June he approved.

The noble Lord said: My Lords, the order is intended to bring the law in Northern Ireland on the removal of eyes or parts of eyes for corneal grafting and for medical education and research into line with the rest of the United Kingdom.

Noble Lords may recall the passage through the House of a Private Member's Bill, introduced in another place by my honourable friend the Member for Exeter, then presented in your Lordships' House by my noble friend Lord Cullen, to become the Corneal Tissue Act 1986. That Act amended the law in Great Britain to allow staff employed by health authorities, who are not medically qualified, to remove eyes from deceased persons subject to proper safeguards. This order replicates those provisions for Northern Ireland. "Replicates" is a word which I do not always use but I understand that it means to repeat identically both the operations carried out as well as the legal requirements. I shall use that word later on.

The purpose of the order is this. As was the case in the rest of the United Kingdom prior to the 1986 Act, the existing law in Northern Ireland—the Human Tissue Act (Northern Ireland) 1962—requires the removal of organs from bodies for medical purposes to be carried out only by registered medical practitioners. In the case of most transplantable organs, such as kidneys, hearts, livers and pancreases, this restriction is necessary and will remain in force. However the removal of eyes is different from the removal of other organs in that it is a comparatively simple technique which does not require the skills of an experienced surgeon and can be carried out several hours after death. The order will amend the existing Northern Ireland Act to permit technicians who are suitably trained and supervised to perform this task.

The point of this is, of course, to increase the supply of tissue for corneal grafting. While there is much interest and support in the Province for corneal grafting we have a shortfall in supply of corneal tissue. The present requirement that corneas be removed only by a qualified doctor is a serious constraint in obtaining tissue. Medical staff have busy clinical schedules and in practice have considerable difficulty finding time to remove corneal tissue from donors, especially those who happen to die elsewhere than in hospitals that have an ophthalmic surgery department. This in turn means that many corneal grafts are performed as emergency procedures as and when suitable tissue becomes available. By allowing suitably trained non-medical staff to carry out this comparatively simple procedure it will be possible to increase the supply of tissue from donors whether they die at home or in hospitals.

Tissue—as it is called—can be stored at the eye bank at the Royal Victoria Hospital for up to 14 days. By enabling more tissue to be available for storage the draft order should result in a number of major benefits. First, there should be an increase in the number of corneal grafts carried out. Secondly, ophthalmic surgeons should be able to use their time more effectively because corneal grafting operations can become planned procedures carried out during normal ophthalmic theatre sessions. Thirdly, more tissue will be available for medical education and research purposes.

Of course, there are safeguards in this procedure. It is recognised that where removal of corneas from bodies is to be undertaken by staff who are not medically qualified, safeguards are necessary to ensure that the procedure is undertaken competently and sensitively. The safeguards need to be flexible enough to ensure that the procurement of tissue is not unnecessarily constrained yet firm enough to ensure that the interests of the donor are protected and due regard is given to the sensitivities of relatives. There are four safeguards in the order designed to achieve this delicate balance.

The first safeguard is that only employees of a health and social services board will be permitted to remove corneal tissue. This should ensure that tissue is removed only by technicians who have been properly trained and who are subject to whatever procedures their employing authority considers necessary. At the same time any private hospitals wishing to undertake corneal grafting will be able to obtain tissue either by making an arrangement with a board or through their own doctors collecting tissue.

The second safeguard is that non-medical staff may remove eyes only if they are acting under a doctor's instructions. The doctor would, of course, be professionally accountable for any instructions he gave. The third safeguard places a responsibility on the doctor who gives the instructions to satisfy himself that the staff he instructs are suitably trained and qualified.

I stress that the medical profession is happy to accept this responsibility. Noble Lords will be interested to know that following the coming into operation of the Corneal Tissue Act 1986, the United Kingdom transplant service in Bristol has set up an eye retrieval course to train technicians to carry out this task and I am happy to say that the course will be available to Northern Ireland staff.

The fourth safeguard will ensure that the certification of death will remain very firmly the prerogative of the medical profession. It would be totally wrong for corneal tissue to be removed before death has been properly certified by a doctor. However, to make for the easier application of the provisions of the order the doctor who certifies death must not necessarily be the same doctor as the one who gives the instructions for tissue to be removed.

The provisions of this order have the full support of the medical profession as a whole and the specific agreement of ophthalmic surgeons in Northern Ireland. Corneal grafting is a procedure which can safeguard or, far better, restore sight. Your Lordships will agree that it is of the utmost importance that an adequate supply of tissue is available to keep the eye bank at the Royal Victoria Hospital well stocked. No one in need of this type of operation should be denied that opportunity because of the shortage of tissue. Corneal tissue has not in the past been collected from many potential donors. This order will remove the single greatest impediment to the collection of that tissue; namely, the need for it to be collected by a doctor.

I referred to the Corneal Tissue Act which was instigated by my honourable friend the Member for Exeter and conducted through this House by my noble friend Lord Cullen. That Act, which came into force two years ago, has operated with much success in Great Britain—that is, on the mainland of England, Scotland and Wales. I commend both my honourable friend the Member for Exeter and my noble friend Lord Cullen for their efforts in bringing forward that legislation which had the full support of the Government. We believe that it is highly desirable that patients in Northern Ireland should enjoy the benefits of similar legislation. With that in mind I commend the order to your Lordships.

Moved, That the draft order laid before the House on 28th June be approved. (Lord Lyell.)

7.45 p.m.

Lord Graham of Edmonton

My Lords, we give our warm and unqualified support from these Benches to the Minister and his colleagues in bringing forward this order. I am delighted that in doing so the Minister paid tribute to the work of the honourable Member for Exeter, Mr. John Hannam, who is well known to me and who has my highest respect in this and many other matters. It was right that the Minister should draw the attention of the House to the part played by the noble Lord, Lord Cullen. As we know, the noble Lord had a major parliamentary victory yesterday in this House on another matter relating to eyes. That bears repeating, at least from this side of the Chamber if not from the Government side.

The raison d'être for the order is well understood. I am grateful to the Minister for the care he took in his very lucid speech. There will be many people who read the proceedings of this House—and I am one—who are not always aware of the nuances of matters of this kind. Therefore, I express my sincere thanks to the Minister. However, the noble Lord can perhaps tell us why a measure which was seen to be wholly appropriate in 1986 has taken two years to reach this House in respect of Northern Ireland. There can be no argument about the good sense of the measures contained in the Corneal Tissue Act 1986. I should have thought that we might have seen this order a little earlier. I look forward to hearing the Minister's comments in that respect.

I understand the raison d'être for the order. It is related to pressure on the time and the ability of properly qualified people to be able to deal expeditiously with needs as they arise. However, can the Minister tell the House whether there is anything different in the Northern Ireland scene compared with any other part of the British Isles in regard to special needs? I understand, of course, the difference between Northern Ireland legislation and legislation for the rest of Great Britain. But is there anything foreboding in the Northern Ireland scene which calls for special treatment? We know that, tragically, there are many differences about life in Northern Ireland compared to that on the mainland.

The Minister said that the primary purpose of the order is to increase the supply of tissue in order to meet a shortage. He said—without giving statistics, which I respect—that there must have been many instances where there has been a loss to potential recipients of a graft as a result of a deficiency in the law which this order corrects. We certainly understand that.

I put to the Minister a number of questions related to the main body of this subject on page 2 of the order. The Minister rightly drew attention to the manner in which a person in the employment of a health and social services board acting on the instructions of a registered medical practitioner is given new powers or opportunities under the order. Can the Minister give some designations of what and who those people will be? For instance, it simply states: a person in the employment of'. What is the designation and the status of the individuals who will be represented by those words? Whoever the persons are they will he competent and qualified. The medical practitioner has to be satisfied that the persons in question are sufficiently qualified and trained. Can the Minister say what they will be called? I was particularly interested in what the Minister told us as regards the eye retrieval course at the UK transplant centre in Bristol. I am wondering whether there are qualifications, diplomas or certificates which will make it easier to identify the individuals concerned.

The terminology at page 2 (4) quite properly makes direct reference to the examination of the body to ensure that life is extinct. That must go without saying, but can the Minister say whether there have been any tragic circumstances in which an attempt was made to deal with the need for a corneal graft and transfer when in fact—horror of horrors!—the body has not been extinct? Perhaps the Minister can say whether it is right that those words should be in the Bill. Can he also tell us whether what we are discussing is based upon some sad experience?

The order states under (4A)(a): a registered medical practitioner, who must have satisfied himself by personal examination of the body that life is extinct, or (b) a person in the employment of a health and social services board". The Minister said that that person will be under the instructions of a qualified medical practitioner. How are those instructions to be conveyed; are they to be conveyed in writing? One understands that when mistakes occur very often there is some uncertainty as to precisely what were the orders. Not everyone who is found to be at fault is prepared to own up immediately.

When we are talking about someone who is under the supervision of another, how are the lines of communication to be established? Is it a question of by word of mouth; is it a question of a general understanding based upon the qualification of the person? I shall be glad if the Minister and his colleagues give some thought as to how it is that the powers of the supervisor are to be transferred to the supervised person in order that there can be no doubt. I am not talking about any shady practice, but about the care to be taken to ensure that whoever carries out these duties is clearly instructed and supervised. We certainly give a very warm welcome to this order.

Lord Lyell

My Lords, I am very grateful to the noble Lord, Lord Graham, and for the attention that he has paid to this short but complicated and, I hope, fairly sensitively presented order. I wish to thank him for the encomium that he has paid to my honourable and noble friends who will read what has been said this evening. I note particularly what the noble Lord said last night about my noble friend as regards reading. Fortunately, I am still able to read, though from time to time I find it hard to identify your Lordships on the other side of the Chamber in conditions of poor light.

Quite rightly, the noble Lord pointed out that this order and the Corneal Tissue Act 1986 are fraught with a certain delicate area where relatives of a deceased person may have to be asked sensitively if they have any objection to the deceased relative becoming a donor. As your Lordships will be aware, on the mainland (and as far as I am aware also in Northern Ireland) persons may carry a donor card. That will refer to the removal of other organs about which I have spoken earlier.

The main thrust of the order before us this evening deals with the removal of corneas and corneal tissue particularly in view of the delicacy of the time factor. I stated that time was of the essence. I understand that a reasonable time is anything below 14 hours after death. This is subject to all kinds of conditions. The first note I have refers to delay and not necessarily as regards the removal of the tissue. The noble Lord asked why it had taken quite so long (nearly two years) to bring Northern Ireland into line with Great Britain. So far as I am aware, this is the first opportunity that we have had to bring an order before your Lordships. I suspect that there is also a period of consultation in Northern Ireland as regards the carrying out of this procedure.

I am quite sure that the technicians and the qualified people, though not fully medically qualified—they are not doctors—are qualified to carry out this fairly simple operation. I suspect that there have been consultations and that once necessary consultations had been completed, then the normal legislative procedure was started. That would account for the delay. If there has been any major obstacle, I shall write to the noble Lord.

As far as I am aware, on a statistical basis there is no major difference in eye maladies—if I may call them that—in Northern Ireland other than the normal divergencies. I understand that corneal transplants or the transplant of corneal tissue, is useful in a number of ophthalmic diseases or problems. I am not aware of any divergence from the average in Great Britain. Certainly, there is no serious shortage of corneal tissue; but as your Lordships will be aware, every single person who can either regain his sight or have it improved or maintained by this miraculous new technique, provides an additional blessing.

The noble Lord asked me three questions. The first related to the qualifications of persons who will carry out what he called the eye retrieval. I understand that those qualifications will be precisely the same as those for a similar person carrying out the removal of corneal tissue in Great Britain. It is for this reason that I stressed the availability of what the noble Lord called the eye retrieval course at Bristol. There are already two technicians, I understand, who will be taking part in this course which I believe lasts for one week. I am convinced that there will be opportunities for people from Northern Ireland who wish to obtain the qualification to carry out this operation.

Lord Graham of Edmonton

My Lords, is the Minister saying that the basic qualification will be taking the course at the eye retrieval centre in Bristol? I am happy to accept that, because quite clearly the noble Lord and his advisers will be satisfied as to the quality and calibre of such a course. However, if he then goes on to say that two people are there now and that there is space for others, I wonder what ambition the Government may have in respect of the numbers.

Lord Lyell

My Lords, if the noble Lord will have patience I shall come to that point. I am not aware of all the precise qualifications which these technicians would require; whether A-levels or O-levels in science, or whatever. I shall endeavour to obtain this information and write to the noble Lord saying exactly who they would be, what such people are doing at present and what the course at Bristol will do for them. The course will be a source of continued improvement in techniques for this delicate operation. I shall write to the noble Lord on that point.

I am not aware of any case of removal of corneal tissue where life had not been certified as extinct. This would have been covered under the 1962 Act, to which I referred at the outset. As I say, I am not aware of any case where removal of corneal tissue has taken place where a doctor has not certified that the life of the donor is extinct. In some cases, which are permitted under the order, as the noble Lord will have noted, the doctor who authorises the qualified person to remove the corneal tissue will receive certification from a second doctor that life is extinct. This will mean that there will not be a wasted journey, perhaps the whole way across the Province, from Belfast to the other side. A doctor in the donor's home town can certify that life is extinct and then the qualified person can obtain the corneal tissue.

Perhaps the noble Lord will remind me about his third question because I am afraid I have lost it.

Lord Graham of Edmonton

My Lords. I was interested in the manner in which the person who will now be covered by the order will carry out what he is allowed to do. When one certifies that a person is dead, how will the responsibility of the supervisor be passed to the supervised? Will it he in writing or in some other form?

Lord Lyell

My Lords, this should be a relatively simple operation. I shall find out and answer the noble Lord, 1 hope, in two lines.

The noble Lord has been perspicacious and kind in the welcome he has given to the order. I do not think your Lordships will wish me to say any more and I commend it to the House.

On Question, Motion agreed to.