Death by a thousand cuts

Sue Kilroe, a 33-year-old housewife, fills in the forms at the Lord Street blood donor clinic in Liverpool. No, she has not had her ears pierced; no, she has not just been on holiday; no, she has not done anything that might affect her blood.

Every three months, since she was 18, Sue has come here to give her pint. She tries not to miss a session at the cheery modern building with the staff she considers friends. "This is the one thing you can do for free. I give blood as a gift of life."

But dozens of others who have sat alongside her at donor sessions for years are giving up in exasperation at changes in the service. "I feel sorry for the patients," says one man from Knotty Ash, "but I feel so strongly that I cannot bring myself to give again." Similar threats have been made in Oxfordshire.

Britain's blood service, once regarded as the best in the world, is beset with problems. The first shadow was cast in the early Eighties, when hundreds of haemophiliacs were found to have been treated with blood contaminated with HIV. Many died. Screening for the virus helped to restore public confidence, but a further scare in 1993 again highlighted the vulnerability of the system: 12 haemophiliacs died of liver disease after contracting hepatitis C from a blood product.

These were major blows to the service. But the past year has seen a series of controversies that may amount to the biggest crisis yet.

First, there was outrage when it emerged that surplus blood products were being sold abroad without the permission of donors. Then in June, thousands of pints of blood in bags made by an Australian company, Tuta, had to be withdrawn after staff at blood centres spotted faulty seals, which risked contaminating the stocks. Critics accused service chiefs of introducing the bags as a cost-cutting measure; the chiefs responded that they were simply finding alternative bag suppliers. Then came the news that Ribena and McVitie were interested in commercial sponsorship of the service (the scheme was promptly dropped in the face of public condemnation).

Many staff and donors have grave doubts about whether the service is being run in the best interests of patients or whether the Government's demand that it should balance its books is overruling wise management. More important, though, is the question of whether the service can meet hospital needs in a context where transplant surgery and modern medicine is increasing demand by up to 4 per cent a year. Is there, as some staff and donors suggest, a real crisis?

On 1 April 1993, the Blood Transfusion Service, set up in 1946, gave way to the National Blood Authority for England and Wales (NBA). The logic was clear. The service had developed ad hoc over half a century. The 15 regional blood transfusion centres did not use the same computer system, so they were unable to establish which blood supplies were available in other parts of the country. Health regions were responsible for running and funding their own blood transfusion centres, and operations were sometimes cancelled while neighbouring authorities were well stocked with blood. There were, as the health minister Gerry Malone explained in the Commons last year, "variable administrative practices, duplication of effort, wasteful use of resources and inadequate co-ordination". A national body could take an overview and organise stocks as necessary.

John Adey, then managing director of Baxter Healthcare, a private company which, among other things, supplied blood bags, was appointed as chief executive of the NBA. He immediately set about modernisation.

Over the summer of 1994, a process of consultation - which cost more than pounds 1m in fees to consultants, itself a bone of contention in the cash- strapped health service - led to a report which mooted the closure of five of the 15 regional transfusion centres, with 400 job cuts. Although blood collection would continue as normal, Liverpool, Lancaster, Oxford, Cambridge and Plymouth would no longer be self-sufficient in stocks and would rely on supplies from elsewhere. Local campaigns were launched to save them. Clinicians warned of the dangers of not having blood banks close to hand.

Last November, after a year's deliberations, Stephen Dorrell, the Health Secretary,announced a compromise. The five centres in question would retain some facilities, but the main work of processing and testing blood would be transferred to the remaining 10. There would be at least 300 redundancies and savings would amount to pounds 10m a year.

Staff were in uproar, warning that the delay had already prompted dozens of key technicians and managers to depart and that this trickle would become a flood as the downgrading of the centres was implemented. They too stressed the dangers of having stocks down the motorway instead of close to hand.

Critics say that the service's new managers do not understand the special nature of Britain's blood system, where donors participate not for money, as in the United States, but out of the goodness of their hearts. They claim that in attempting to make the service more businesslike, the NBA has ignored the donors and jeopardised the goodwill on which the service relies.

Reports that blood products were being sold abroad surfaced a year ago and were initially denied. When the health minister Tom Sackville admitted that this had been going on since at least 1986, donors were stunned. As Tessa Jowell, then a Labour health spokeswoman, pointed out, most would not withhold consent for surpluses to be sold if the reasons were explained, but they should have been asked.

"Donors have always been incredibly parochial and have always wanted to support their own centres," explains Ivor Thompson, a senior scientist at the Lancaster centre. Naively perhaps, they believed that their blood was being used to help local people and were unhappy to learn that it could end up in any number of countries. "I've never been told what my blood's gone for. I've just assumed it's gone for use in this country," says Pauline Swan, a donor in Oxford. The Independent's disclosures in October that in Turkey, for example, the surpluses were sold on at four times the British price fuelled the donors' fury.

Their fears were compounded by an apparent crisis in supplies. Since the second week of December, blood stocks have been below the accepted minimum level of 15,000 units. On Monday, they sank to less than 9,000 units, roughly equivalent to 9,000 pints. A liver transplant might require 100 units, a road accident victim hundreds. Dr Paul Stevenson, a consultant haematologist in Liverpool, says he would have cancelled Monday's routine surgery if he had been told how low stocks were.

The NBA says that its improved management of the blood market means that the service can operate with smaller reserves. "As a national organisation, it is much easier to move stocks around the country to make up shortfalls. We have much better knowledge of what the demand is and what's been collected," says a spokeswoman.

Dr Colin Entwistle, recently retired head of the Oxford service, is unconvinced. "They've got away with it so far, but it's not going to take much to rock the boat," he says. He adds that a patient could bleed to death in the time it might take to transfer stocks from Manchester to Liverpool.

Doctors and scientists say that one problem can wipe out entire stocks. When the Tuta bags proved faulty, it was impossible to withdraw all the affected stocks immediately because there was not enough blood to replace them. A few days later, 33-year-old Stephen Legg was fighting for his life after contracting septicaemia from bacteria in a bag which had not been withdrawn.

"You have to cater for the unexpected and they aren't doing that," one scientist argues. "If there had been 20,000 units, they could have withdrawn all the bags and Mr Legg would never have been in that state.

"They're experimenting with much lower stock control than has been accepted before," says another. "How close to the line will they take it? Will they wait until someone dies?"