News and issues that affect organ and tissue transplantation
Australia, Canada and the United Kingdom launch national programs
In an effort to boost organ donor rates dramatically, Australia, Canada and the United Kingdom recently redesigned their regionally based transplantation systems into national programs. Their donor rates have consistently been among the lowest internationally, according to 2006 and 2007 statistics.1
While Australia and the U.K. conducted studies and garnered the input of stakeholders before national programs were announced, Canada took a slightly different approach. Canadian Blood Services (CBS) was designated by the federal, provincial and territorial ministries of health (except Quebec) to oversee a new national program. CBS then reached out to transplant professionals, organ procurement organizations (OPOs), government officials and others for input on what the new program should look like.
The amounts invested in each program are listed in Table 1. However, Sally Johnson, the U.K.'s director of organ donation and transplantation in the National Health System's Blood and Transplant (NHSBT) program, notes that, “when making financial comparisons with other health systems, it is important to be clear that they don't all start from the same baseline.”
| Total allocated || $151.1 million over 4 years || $35 million over 5 years || £55 million over 3 years |
|(equivalent amounts)||($122.7 million CAD, £67.4 million GBP)||($43 million AUS, £19 million GBP)||($123.4 million AUD, $100.1 milion CAD)|
For example, the U.K. allocation does not include funding that the Department of Health and their counterparts in Scotland, Wales and Northern Ireland are committing to implementation, Johnson says. Nor do they cover the cost of the increased number of transplants that will take place as the program succeeds.
But skepticism remains. Philip F. Halloran, MD, PhD, director of the Alberta Transplant Applied Genomics Centre and editor-inchief of the American Journal of Transplantation, stressed that the allocated monies for the Canadian program are “way too little.”
“I think the challenges are obvious given that healthcare delivery services are a provincial domain in Canada,” says Sam D. Shemie, MD, of McGill University Health Centre in Montreal. “However, what people need to understand is that CBS did not ask to take on this role; the provincial governments asked them to do so. In addition, CBS is currently funded by the provinces, not the federal government, for blood. The provinces, except Quebec, have stepped up thus far (whereas they had not before) in funding CBS. But there will be a need for further funding.”
Momentum Is High in Australia
In 2006, Australia began a push for an improved system. They formed the National Clinical Taskforce on Organ and Tissue Donation and Transplantation, chaired by Jeremy Chapman, MD, director of renal medicine at Westmead Hospital in Sydney, and sought input from all sectors of the community. All these processes came together with the same conclusions: Australia needed a national approach to transplantation.
The plan includes the development of a national authority to oversee the program and provide funding for employment of trained medical specialists and other staff dedicated to organ donation, to increase hospital staffing and infrastructure, to raise community awareness and to provide counselors to support donor families.
Australian Prime Minister Kevin Rudd was a strong proponent of the plan and, this month, the Australian Organ and Tissue Donation and Transplantation Authority is expected to begin operations.
When speaking before the Australian House, Rudd told his audience that Australia's donor-per-million rate was only 9.8, compared with rates of 33.8 in Spain and 26.9 in the U.S. “We need to do much, much better,” he says. “The government has committed $151.1 million, including $136.4 million in new funds. This is not cheap. To do it well takes money, and we are determined to invest this money.”
Canada Defers to Blood Agency
Graham Sher, MD, CEO of CBS, is optimistic about the development of a national system in Canada, but adds that “a great deal more work has to be done in determining the optimal structure for this system, including the various roles at the national, provincial and local levels.”
After CBS was named to oversee the national program, the organization invited transplant professionals, international experts, organ donor family representatives, healthcare administrators, organ procurement representatives and government officials, among others, to a meeting in Ottawa last September.
Dr. Halloran notes, however, that there was “no opportunity for a consensus exercise by stakeholders” prior to the decision for CBS to run the national program. “The CBS decision by the federal government was made without stakeholder input, with only civil servants involved,” he says, adding that there is “no accountability or obligatory reporting and no performance standards. The window-dressing meeting in Ottawa after the fact was a public relations exercise by CBS; they have no obligation to listen.”
On the other hand, Dr. Sher believes the Ottawa meeting offered an opportunity for the system to be built in a consultative way. In addition to reaching a consensus that a national, integrated system was needed, the attendees wanted CBS to set standards and develop policies, monitor and drive strategy, enable best-practice sharing and engage in national awareness and education campaigns.
When asked about the challenge of getting provincial OPOs to buy in to a national system, Dr. Sher says, “While some participants called for the abolition of the OPOs, the consensus emerged loud and clear that there's an important role for OPOs; the system will require both regional programs and a national player.”
One of the meeting attendees was John Gill, MD, assistant professor of nephrology at the University of British Columbia in Vancouver, and first author of an American Journal of Transplantation article describing the Canadian donation system.2 Noting that he's cautiously optimistic about the new national system, Dr. Gill says he was concerned with the initial decision to go with CBS because “there wasn't a widespread consultation.”
However, he was impressed with the three-day meeting in Ottawa. “On day one we were quite skeptical about the program. But it became clear that they were truly looking for the opinion of the transplant community.”
He said several participants expressed concern that the $7 million initial investment would only be a small portion of CBS' $900 million yearly budget. “Is it going to get buried in this big bureaucratic organization?” he and others asked.
Dr. Sher says that CBS “is accustomed to managing different business lines with the due attention they need.”
Meanwhile, Quebec had not yet signed on to the national program by press time, in spite of pressure from transplant professionals. “There's a great deal of concern that the government isn't participating in this plan. From our perspective, there's no obvious medical reason why Quebec would benefit from not being a part of this,” says Steven Paraskevas, MD, PhD, a transplant surgeon and researcher at Quebec's McGill University Health Centre.
This is not cheap. To do it well takes money, and we are determined to invest this money.
—Australian Prime Minister Kevin Rudd
U.K. Donation Run by National Organization
Following a comprehensive report by the Organ Donation Taskforce, set up in 2006 to identify barriers to organ donation, the U.K. has designated the NHSBT as the national authority to oversee organ donation and transplantation on a national level.3 The new Organ Donation and Transplantation directorate within the NHSBT incorporates what was U.K. Transplant, and the process of transferring existing donor transplant coordinators (DTCs) from their current hospital employment into larger teams with the NHSBT is under way. Four DTC teams are expected to be in place by March, with the remainder to form later this year or in 2010.
Setting up a national agency and moving DTCs into the national system were two of 14 recommendations from the taskforce. “The 14 recommendations were accepted in full by the government,” Johnson says. “The report makes clear that the implementation of all 14 recommendations is integral to the delivery of the 50% increase in organ donation over the next five years.”
Another recommendation was the development of electronic online registries. In late September 2008, the NHSBT began a live pilot of an electronic donor registration and organ offering system in the Manchester and Cambridge areas. When fully implemented, this system is expected to speed up the transmission of donor information to recipient hospitals and enable faster organ allocation.
Additional recommendations included:
- • The removal of financial disincentives to trusts;
- • Brain stem death testing in all patients where it's a likely diagnosis;
- • Mandatory training in the treatment of potential organ donors;
- • The identification of appropriate recognition for donors; and
- • Research on how best to promote organ donation, especially to minority and ethnic populations.
According to Johnson, the current key focus of the NHSBT is employment and consistent working practices for DTCs, the appointment of donor champions and establishment of donation committees in every hospital in the U.K. and commissioning a national organ retrieval service.