NHS transplant chief warns of 'fragmented' system failing patients

Professor Derek Manas, the medical director of NHS Blood and Transplant, has written a damning assessment of how England's transplant system is failing patients. In a letter obtained by the BBC and addressed to NHS England leadership and patient advocates, he describes a service fractured by poor planning, burnt-out surgeons, and a management structure that creates chaos where coordination should exist.

The numbers tell part of the story. For three decades, the number of heart and lung transplants performed by the NHS has flatlined. England was once a world leader in this field. Now it transplants only one in ten donated lungs and one in seven donated hearts—half the rate of comparable wealthy nations. The gap reflects not a shortage of donated organs, but a shortage of capacity, expertise, and will to use what becomes available.

Manas identifies the root problem as structural fragmentation. Each hospital maintains its own waiting list. Organ availability fluctuates unpredictably. Operating theatres sit empty or overbooked. No one is managing the system as a whole. The result is last-minute cancellations that leave patients in limbo and donated organs unused. Waiting times for a heart transplant can stretch from eight months to four and a half years, depending which hospital a patient is assigned to. There is no fairness in this, only geography and chance.

The human toll compounds the inefficiency. Half of the six major heart and lung transplant centres in the UK have lost their lead surgeon in the past two years. These specialists are leaving for opportunities abroad, driven out by inadequate staffing, relentless pressure, and the expectation that they will simply absorb whatever workload appears. Manas describes a system that assumes surgeons and their teams will run on goodwill indefinitely. That assumption is breaking down. Recruitment has become difficult. Retention is worse. The remaining staff are burning out.

The geography of the problem extends beyond England's borders. Wales and Northern Ireland have no heart and lung transplant centres. Scotland has one. Patients from these nations must travel to England for surgery, adding logistical burden to medical urgency. For some, the journey itself becomes part of the ordeal.

Manas is not alone in his criticism. Dr Zubir Ahmed, a kidney transplant surgeon who served as health minister responsible for transplantation until May, told the BBC that elements of the system are world-leading—organ transplantation is free at the point of care, which is not true everywhere. But he argues the structure is broken. He has called for NHS Blood and Transplant to be granted power to commission services across all four nations, so that patients can be moved swiftly to whichever centre has capacity. "I don't think there is ever a need to cancel a transplant because of capacity issues," Ahmed said. That statement alone measures the distance between what the system could be and what it is.

NHS England has responded to the criticism by saying it is working hard to improve these services. The organisation points to a programme of work aimed at increasing transplant numbers, reducing variation between centres, identifying suitable patients earlier, and improving access. But surgeons and patient advocates say progress has been slow. A report by international experts, commissioned by the previous government in 2024, outlined these problems in detail. The recommendations have not been fully implemented. The waiting lists have not shortened. The surgeons have not stopped leaving.

What happens next depends on whether the current government acts on what Manas and others are saying. The system is not broken by accident. It is broken by design—or rather, by the absence of design. Someone will have to decide whether to fix it.