Examination of Witnesses (Questions 120
MONDAY 29 JANUARY 2001
120. This figure of 88 per cent, 88 per cent
of the blood actually ends up inside another body, that is great,
but still 12 per cent is lost. You seemed to intimate that was
a very good figure. Does that mean that 12 out of every 100 people
who take the trouble to go and give their blood and spend an hour
doing it are just completely wasting their time? Is this such
a good figure? Why is this blood lost? Is it just the wrong quality
or does it hang around too long? What happens to it?
(Mr Gorham) No. In fact, I am pleased to say that
time expiry, it has been in store too long to use, is a relatively
low proportion of the losses. We do try to make sure everything
that is possible gets used. Some of it is used for quality control
tests and things like that.
121. But 12 per cent is very high.
(Mr Gorham) No, not 12 per cent. If you start off
with 100 per cent of the donors, and again I refer you to the
chart on page ten, you will see that there are some losses at
the session, sometimes because we cannot get a complete donation
or for some other reason, and there are inevitably processing
losses and the leucodepletion process, the process of removing
white cells, has increased that. It has actually increased it
less than we feared it would, we have been more successful in
controlling that than we thought. I think it is inevitable that
there will be some loss at hospitals because they need to hold
stocks and certainly for some groups it is just not possible for
them to use all of the stocks. Having said that, all of us involved
in this are concerned to get that figure down as low as possible.
122. Do you think you can make an improvement
on that figure?
(Mr Gorham) We have made an improvement in the last
year and, therefore, we think we can continue to improve it, yes.
It will remain one of our key targets for improvement. We will
press to improve it for as long as we can get improvements out
123. What action can the NHS Executive take
to encourage hospitals to be vigilant in the use of transfused
blood to ensure that they give patients the right blood? I am
referring to paragraph 4.3, perhaps to the Chief Executive of
the National Health Service. This is topical in the light of the
appalling tragedy a couple of weeks ago when a hospital injected
the wrong thing into somebody's spine who was suffering from leukaemia.
That is the greatest fear people have, is it not, being given
the wrong blood?
(Mr Crisp) I think there are two or three things.
The first one is the one you have pulled out here which is the
use of this process of Serious Hazards of Transfusion and making
sure that we do identify things as they go wrong. We have also
got now, as I mentioned earlier, a much closer relationship between
the Blood Service and the NHS hospitals and it is, if you like,
part of my role, I guess, to make sure that hospitals are taking
that relationship seriously and as part of their responsibility
to ensure that they are actually working with Mr Gorham and colleagues
to make the best use of the blood that they are getting, to use
it safely, to have appropriate and standard practices and so on.
124. Can you give me a rough idea of what proportion
of cases do go wrong? What is the figure we are talking about
who were given the wrong blood? How common is it? Just give me
a rough idea. This is my very last question.
(Mr Crisp) You will note here that there were seven
deaths associated with it, which was out of five million transfusions.
I do not know about the other figure. I do not know whether Mr
Gorham has got a figure for the number?
125. Obviously it is very, very small. For the
people concerned it is quite serious.
(Mr Crisp) Absolutely.
126. Is it so small as to be statistically insignificant?
(Mr Gorham) It is sufficiently large to concern us.
We are actually following up the recommendation at the bottom
of this paragraph about evaluating computerised identification
systems. We have allocated £120,000 of our blood safety research
fund for this next year to follow up on that work. Although it
is a small number it is avoidable and, therefore, and we should
do everything we can to avoid it.
Mr Leigh: Thank you.
127. Just as a matter of interest, I read on
page 11, paragraph 17.22 that you bought plasma from America,
or some of it. Is plasma obtained from anywhere else, is it obtained
(Mr Crisp) Not by the English Blood Service, to my
128. You only buy from America.
(Mr Gorham) That is for the Bio-Products Laboratory.
129. How much better is the Service now than
it was pre 1998, when the then Secretary of State had to make
the announcement to the House?
(Mr Gorham) I suppose the most obvious improvement
that we would draw attention to is that we have provided a continuous
supply of safe blood. First and foremost, our job is to make sure
we can supply blood to hospitals when and how they want it.
130. It was very frightening reading the statement
the Secretary of State made at the time. It, more or less, gave
the impression that the Service was in danger of collapse.
(Mr Gorham) I cannot comment on that because I did
not join the Service until some six months later.
131. You must know what the feeling was?
(Mr Gorham) The Service has, very clearly, been through
a very difficult time. That has had an adverse effect. The second
thing I would say is that we have worked very hard to get morale
back up, to get people to feel positive about what they do again
and encourage them to do the things they are capable of doing.
132. Is morale better now?
(Mr Gorham) I think so, yes. I do not have an objective
measure. As I said before I do spend quite a bit of my time out
around the Service and, generally, attitudes are better, the feeling
is better. You can walk into some of the centres where before
you felt you were hitting a wall, you do not feel like that any
more. The third thing I would point to is, by virtue of having
created the national structure we do have the ability to work
on standards on a national basis and we also have the ability
to focus expertise on a national basis. In terms of meeting our
national planning commitment, to offer common access to services
throughout the country, we have put ourselves in a position to
really develop that.
133. Are you not getting any complaints from
Members of Parliament?
(Mr Gorham) We get some, as obviously you will in
a large service that is constantly in touch with the public.
134. Right. Okay. Page 17, paragraph 2.14. We
recently did a report, last week, an investigation into risk management
in government departments. It was quite refreshing to read in
2.14, where it seems to indicate, "The National Blood Service
recognised and took action to avoid this by increasing their collection
of O negative blood". There seemed to be a problem arising
and action was taken to prevent the problem occurring. That is
obviously very good, would you say that is typical of the Service?
(Mr Gorham) I think the Service enjoys a group of
staff who are very committed to what they do and very thoughtful
about what they do, because of their background they understand
the whole concept of risk management and take it very seriously.
The way in which we have been able to improve our contingency
planning, initially stimulated by the millennium, over the last
couple of years is very encouraging. We are applying risk management
assessment to all of our business plans for next year at the moment.
We see it as a critical part of corporate governance, the control
assurance aspect of our work. We do take it very seriously.
135. Right. On page 19, 2.21, it seems a bit
contradictory because it says, "At the time of our visits
in 1999, only one blood centre, Southampton, had analysed the
risk of supply being interrupted and produced a contingency plan,
though they have not maintained their plan and it was some 18
months out of date". That is a little bit contradictory to
what you are saying.
(Mr Gorham) We have moved on from there.
136. Only one blood centre had a contingency
plan, that is not very good, is it?
(Mr Gorham) It was not very good. We have moved on
from there. That was the situation we found and it would not do
and we changed it.
137. Why was that allowed to happen?
(Mr Gorham) I do not know, I was not there.
138. It will not happen again.
(Mr Gorham) Most certainly not.
139. It does seem incredible that very few had
thought about what they should do if the supplies had been interrupted.
(Mr Gorham) I think it is one of the reasons why it
was so important to form the National Blood Authority in the first
place. I think everybody was working very hard, they are certainly
still working very hard. There was not enough attention being
given to the broader aspects of managing the Service. I think
one of the things we have to achieve is to pay the right attention
to those broader aspects of managing the Service so that we can
assure the quality of the Service overall.