How the UK’s transplant system deteriorated

The UK was once a “world leader” in organ transplants, said the BBC’s “File on 4 Investigates”. But it has “fallen behind”.

In 2024, the number of heart transplants carried out per million people in the UK was lower than in most European countries, thanks to a lack of investment, resources and “outdated” technology. Waiting lists for organs are at a record high, while family consent rates for donation have fallen dramatically since the “opt-out” presumed consent system was implemented.

What’s going wrong?

“Organ donation is in crisis,” said Martha Gill in The Observer. Last year, the waiting list for an organ reached its highest on record, according to NHS Blood and Transplant: an 8% year-on-year increase. “As a consequence, many will die waiting for a phone call.”

There are only five heart and lung transplant centres in England, and one heart transplant centre in Glasgow. Anyone living in Wales or Northern Ireland must travel for a transplant, and there is significant regional variation in waiting times.

Half of the six main centres have also “lost their top surgeon in the past two years”, said the BBC. Others are leaving for jobs abroad: a “brain drain” of experts. Without experienced mentors, junior surgeons are increasingly “risk averse” and only using the healthiest donated organs, said Jorge Mascaro, Birmingham’s former director of cardiothoracic transplants (now based in the US). “It’s getting worse.”

The number of organs donated in the UK per head is equal to, or greater than, most of Europe. But the NHS transplants far fewer hearts and lungs than most countries, said the BBC. “Some countries make use of twice as many.” Surgeons say this is down to a lack of equipment and new technologies used abroad, such as machines that can scan organs to check if they are diseased. Ice boxes are often still used to transport organs between hospitals, which can harden them.

Operations are also regularly cancelled thanks to a lack of theatre space, hospital beds or staff. Post-transplant patient care is crucial to prevent complications, but the NHS “continues to struggle” to provide long-term support: the UK’s five-year survival rates “lag behind”.

Has the opt-out system failed?

When the “opt-out” system of presumed consent was implemented in England in 2020, “expectations were high”, said Gill. But the number of donors has been “crashing”. In the year to March 2025, there was a 7% decrease in the number of deceased organ donors, according to the Organ and Tissue Donation and Transplantation Activity Report. Life-saving transplants also decreased by 2%.

Most people support organ donation in theory, and nearly half the population have signed the Organ Donor Register, according to Organ Donation. But relatives have the final say; family consent rates have dropped from 69% to 61% over the past five years. Surveys suggest a “common reason: they didn’t know what their relative wanted”, said The Observer. The types of deaths that make donation possible – usually traumatic, sudden deaths of young healthy people – make it even harder for families to decide.

The presumed consent of the opt-out system acts as a “weaker signal of underlying preference” than the active consent of an opt-in system, said researchers at the Max Planck Institute for Human Development in a 2024 paper. This “uncertainty” means families are “more likely to refuse consent”. Evidence suggests an opt-out model alone doesn’t boost donations: it must be accompanied by a framework of logistics, psychological support and education.

What can be done?

The NHS and campaigners are calling for “better education in schools”, said The Mirror: for organ donation to be included in curriculums, and campaigns particularly targeted at ethnic minorities (among whom the family consent rate is significantly lower).

Evidence suggests an opt-out model alone doesn’t boost donations. Countries must invest in healthcare infrastructure, psychological support for families, and public awareness campaigns to encourage people to discuss their wishes. Family consent rates increase to almost 90% if the deceased has done so.

A government-commissioned review of heart and lung transplant services, published in 2024, made various recommendations, including better holistic care, a single-service model across the multiple centres, and “rapid-short term actions to improve organ acceptance decision-making”, said NHS England.

NHS England has since been abolished; responsibility for transplant services now lies with the Department of Health and Social Care. In a statement to the BBC, the department said the government had inherited a broken NHS, and that it recognised the “systemic issues” facing transplantation. The government said it would write to the NHS demanding that it “urgently implement” the recommendations, to make transplant services “fit for the future”.