Human Tissue (Authorisation) (Scotland) Bill: BRIA

4.0 Options

4.1 Sectors and groups affected

Background

Organ donation and the allocation of organs to transplant recipients is managed across the UK by NHS Blood and Transplant ( NHSBT). Organs need to be carefully matched to a recipient, taking into account things like the blood group, age, weight and the tissue type of the donor and potential recipient. This is important to give the best possible chance for a transplant to be successful. If an organ is not a good match with the recipient, there is a significant risk that it won't function effectively.

NHSBT is responsible for managing the UK's national transplant waiting list and for matching and allocating organs on a UK-wide basis. While this means that some organs from donors in Scotland may go to people in other parts of the UK (and occasionally elsewhere in Europe), it also means that people in Scotland may receive an organ from elsewhere in the UK or the rest of Europe.

While donated organs can normally be retrieved at most acute hospitals, there are three transplant units in Scotland, which each have specialist facilities dedicated to the transplantation of organs into recipient patients:

• The Royal Infirmary of Edinburgh (liver, kidney, pancreas and islet cell transplants)
• The Queen Elizabeth University Hospital, Glasgow (kidney transplants)
• The Golden Jubilee National Hospital, Clydebank (heart transplants)

Most Scottish patients have their transplant undertaken in one of the three Scottish transplant units. However, a small number of Scottish patients receive their transplant in other parts of the UK. These usually relate to rarer transplants where it is in the best interest of patients to receive transplants in specialist centres. These treatments are fully paid for by NHS Scotland.

Meanwhile, most tissue donation in Scotland is managed by the Scottish National Blood Transfusion Service ( SNBTS), although NHSBT manages donation of eyes across the UK. SNBTS has its own Tissue Donor Co-ordinators ( TDCs), specialist nurses who work closely with NHSBT SNODs to coordinate donations in cases where both organs and tissue may be donated.

4.2 Costs and Benefits

As a result of the introduction of the Bill it is anticipated that the organisations and individuals affected will include: families of donors, recipients, families of recipients, the Health Service (transplant facilities including staff and other hospital services), wider society and government. The costs and benefits of a change of legislation for organ donation will be wider than just the operational costs and benefits that a potentially wider pool of authorised donors will have. The costs and benefits will also apply to potentially extendiong the life of additional organ recipients. A range of economic and financial costs and benefits have been presented below for the different options.

Option 1 - Do nothing. The do nothing option will not alter the status quo in legislative terms. This option will provide the baseline against which the impact of the introduction of this legislation will be measured.

Option 2 – Soft opt-out system for organ donation.

This option proposes a soft opt out system for organ and tissue donation. Under this option adults (except for those in certain categories) could be deemed to have authorised donation if they have not opted out, but it allows for family members to advise of any objection the individual had to donation; meaning that donation wouldn't proceed if the potential donor would not have been willing to donate.

It is not possible to identify with any certainty the impact on organ donor numbers and transplants as a result of the opt out system. Any increase could also be attributable to other measures underway to increase organ donation and transplantation, for example: the use of novel technologies. Therefore, growth might not necessarily be directly attributable to the introduction of the opt-out system. Nevertheless, a cost benefit analysis has been undertaken which estimates the number of additional donors which may be attributed to an opt-out system can be found below.

For the purposes of this analysis, increases in activity are assumed to be as a result of the policy only, and are net of any long term trend or targets. Note that, any increase in activity is assumed to take place in the first year after implementation and is then assumed to be constant (a constant incremental difference from the baseline) in subsequent years. This is due to the underlying complexities and year-on-year variation which make it difficult to predict more accurate long-term trends.

Costs

The financial cost of the Bill will fall mostly to the Scottish Government through direct funding of public information across the population and costs of evaluation of the opt out system. Other costs will fall to bodies funded indirectly by the Scottish Government i.e. NHS Blood and Transplant ( NHSBT), which is responsible for the NHS organ donor register, for Specialist Nurses for Organ Donation, for retrieval services across the UK and for eye donation, NHS National Services Scotland's Scottish National Blood Transfusion Service ( SNBTS), which is responsible for tissue services (excluding eye donation) and its National Services Division ( NSD), which commissions transplant services for Scottish Patients.

The NHS Blood and Transplant ( NHSBT) and the Scottish National Blood Transfusion Service ( SNBTS) have provided an assessment of the likely impact of an introduction of a presumed authorisation system – or soft-opt out – for organ and tissue donation in Scotland.

The analysis presented here utilises 3 main scenarios:

• Low estimate: the "do nothing" scenario which sees no increase in donors or transplants
• Best estimate: the central estimate of NHSBT's modelling, in which the authorisation rate in Scotland increases to 65%, with an estimated 12 new donors, and 28 successful organ transplants per annum.
• Upper estimate: also based on NHSBT's estimate under a 65% authorisation rate, but utilising the upper end of the possible range, with an estimated 24 new donors and 59 successful organ transplants per annum.

In order to capture the impact of the proposed new system for organ donation it is necessary to measure what the costs and benefits of this change will be in relation to option one or 'do nothing' option. This is in effect the baseline or 'counterfactual' against which we will assess the impact of option 2 (the 'preferred option').

Future projections of costs were discounted at 3.5 ^[27] % and benefits, measured in Quality Adjusted Life Years ( QALYs) at 1.5 ^[28] % to derive Present Costs and Present Values.

The costs of the Bill are predicated on the costs of preparation for implementation of the soft opt-out system. As such, Year One (2019-20) will consist of a preparation and implementation phase for training public awareness etc. with implementation at some point during Year Two (2020-21). Please note that for costings purposes, a start date for the implementation of opt out of 1 April 2020 has been assumed, although implementation may well start later in that year (in which case there would be a proportionate reduction in the recurring costs for 2020-21).

Public Information

Section 1 of the 2006 Act places a statutory requirement on Scottish Ministers to promote, support and develop programmes of transplantation and promote information and awareness about donation. This information requirement is currently met in a numbers of ways, including through high profile public information media campaigns held each year. These campaigns have been instrumental in increasing registrations on the organ donor register. The campaigns are supplemented throughout the year by targeted information, for example for students, on-going social media activity, an internationally-recognised schools educational pack and work undertaken by Kidney Research UK peer educators to raise awareness of organ donation among South Asian communities, as well as information being provided at public events.

In addition to the current duty, the Bill will also require Scottish Ministers to promote public awareness of the implications of the circumstances in which authorisation may be deemed. This will necessitate the development of new public information and changes to current messages around organ and tissue donation to ensure that the public understand the implications of the system. The consultation on increasing organ and tissue donation envisaged a high profile public information campaign for at least 12 months before commencement of the system and on a regular basis after implementation of the legislation.

In developing public information, research will be undertaken to gauge people's understanding of the opt out system and to ensure accessibility for different groups e.g. people with disabilities to develop materials which meet different needs. In addition to the regular public information activity and awareness raising, a direct mailing is proposed to all households in the lead up to implementation. Focus groups held with school pupils, people with learning difficulties and young people with experience of being looked after by a local authority as part of the consultation process identified clear and accessible information as a priority so that members of the public could make an informed decision.

For children about to reach the age of 16 there will also be a need to provide information on an on-going basis about the organ and tissue donation system e.g. through direct mailing so that they are aware of the implications. Feedback from focus groups with young people identified individual mailing as one of the preferred methods of communication.

Costs on the Scottish Government for public information and awareness raising for the new system, including pre commencement awareness (Year 1 and 2), are estimated in Table 1.

Table 1

	Year 1 2019-20 £ (m)	Year 2 2020-21 £ (m)	Year 3 2021-22 £ (m)	Year 4 2022-23 £ (m)	Year 5 2023-24 £ (m)	Total
*Public information: development and delivery	0.45	1.405	0.535	0.425	0.275	3.09

*These figures are additional to the £0.250 already allocated annually for public information under the current system. Year 6 costs are estimated at £0.275. From year 7 recurring costs will be approximately £0.425 which includes the £0.250 already allocated under the present system.

• Year 1 includes - research, evaluation design of materials including engagement with organisations to develop and test materials for the general public and specific groups, and production of all materials required for campaign delivery.
• Year 2 includes - direct mailing to all households at a cost of approximately £800,000, and additional media for public information at a cost of approximately £400,000
• Year 3 includes - public information campaign and direct mailings to those about to reach their 16 ^th birthday at an approximate cost of £200,000 around 50,000 people and additional media for public information at a cost of approximately £300,000.
• Years 4, 5 - includes additional media (approximately £200,000 and £100,000 respectively).

Evaluation

Organ donation and transplantation rates are subject to on-going monitoring. Information gathered and published by NHSBT is used to identify trends in authorisation and qualitative information for example: analysis of approaches by Specialist Nurses for organ donation will be used to gauge understanding by donor families of the system, as well as being used to inform training and improvement.

In addition, representative surveys to track public understanding and attitudes toward donation will be undertaken, including using information currently gathered as part of the evaluation of public information campaigns. The effectiveness of the processes in place as a result of the legislation will be evaluated through a process evaluation, used to improve implementation. The additional costs associated with evaluating the impact of the legislation will fall on the Scottish Government and have been estimated as £91,500 spread over years. An impact evaluation will be conducted over a 10 year period to establish the impact of the new system.

Costs on Other Bodies, Individuals and Businesses

NHS Blood and Transplant

While Scotland has its own legislation governing deceased organ and tissue donation, the Organ Donor Register, organ donation and the allocation of organs to transplant recipients is managed across the UK by NHS Blood and Transplant ( NHSBT). Organs need to be carefully matched to a recipient, taking into account things like the blood group, age, weight and the tissue type of the donor and potential recipient. This is important to give the best possible chance for a transplant to be successful. If an organ is not a good match with the recipient, there is a significant risk that it won't function effectively. NHSBT is responsible for managing the UK's national transplant waiting list and for matching, offering, acceptance and retrieval of organs for transplantation on a UK-wide basis. While this means that some organs from donors in Scotland go to people in other parts of the UK, it also means that people in Scotland receive organs from elsewhere in the UK. In the three years from April 2014 to March 2017, 44% of organs from deceased donors in Scottish hospitals went to transplant units in Scotland.

NHSBT Implementation costs ( Table 2)

The Scottish Government provides funding to NHSBT for these services via funding provided to NHS National Services Scotland's National Services Division. It is estimated that NHSBT will incur costs for implementation of the soft opt out system estimated at £376,000 in year 1 and 2. The costs include £163,000 for development and delivery of training; including a half time project management/training and development post in the lead up to and for one year following implementation of the soft opt out system. This position will ensure that clinical staff directly involved in the donation and transplantation process are trained and understand the soft opt out system. It will also be responsible for wider engagement with Organ Donation Committees and clinical teams across NHS Boards not directly involved in organ donation, to raise awareness of the opt out system; ensuring consistent messages and information. Additional costs of £213,000 have been factored in for training of the Organ Donor Register call centre staff and additional mailing, based on experience from the introduction of the system in Wales associated with increased registrations on the Organ Donor Register (both from those opting in and opting out).

However, the recent announcement by the UK Government that it will support legislation aimed at introducing an opt out system in England has resulted in an increase across the UK in registrations to opt out of organ and tissue donation on the assumption that the law in Scotland and England has already changed. This may potentially require some of the anticipated costs resulting from the Bill for the Organ Donor Register staff and additional mailing to be brought forward in part, including potentially incurring some additional costs ahead of Parliamentary consideration. This may however be necessary to make sure that any opt out registrations are processed promptly in order to ensure the Register is always up to date. The workload of the ODR team will continue to be monitored closed with NHSBT.

NHSBT Recurring costs ( Table 2)

To reflect lessons from the introduction of the soft opt out system in Wales, NHSBT intends to introduce the role of Specialist Requester to help with the introduction of opt out. This is with the intention of maximising authorisation from the start; learning lessons from the experience of introducing opt out in Wales. A lower level of approaches to families was experienced in Wales in potential deemed authorisation cases. (This was at the same time triage and screening was introduced so all UK approach rates went down at this time). Recent pilot schemes of specialist requesters have shown an increase in authorisation rates under the current "opt in" system in England, in particular where requesters have been involved in significant numbers of approaches to families.

Currently Specialist Nurses for Organ Donation ( SNOD) lead on the whole organ donation and much of the tissue donation process from solid organ donors, from the approach to the family to the point the dispatch of organs to transplant units. The Specialist Requestor would assume the role of navigating and supporting the family through the authorisation process. Doing so would allow the SNOD to focus on the clinical side of the process where donation is authorised, for example: arranging the appropriate tests and donor characterisation, liaising with transplant centres and co-ordinating the organ retrieval process. Specialist requester resource would be expected to start in 2019-20 in order to allow for training and development of experience prior to the introduction of an opt out system, with an anticipated recurring cost of up to £257,000 per annum.

Provisional recurring costs of up to have also been factored in to cover the increased registrations on the Organ Donor Register and to cover any additional costs which may arise from a potential increase in non-proceeding donors (where the donation is authorised and the retrieval team travel to the hospital, but unfortunately it is unable to proceed).

Recurring costs of £114,000 per annum from 2020-21 have been included for increased retrieval team and SNOD activity.

The phasing of costs reflect the need to be prepared in advance of commencement of the soft opt out system.

Table 2

	Year 1 2019-20 £ (m)	Year 2 2020- 21 £ (m)	Year 3 2021-22 £ (m)	Year 4 2022-23 £ (m)	Year 5 2023-24 £ (m)	Total £ (m)
Non recurring costs
Implementation (one off)	0.330	0.046	0	0	0	0.376
Total	0.330	0.046	0	0	0	0.376
Recurring costs
Specialist requestors	0.257	0.257	0.257	0.257	0.257	1.285
ODR team - additional staff & mailing costs	0.040	0.040	0.040	0.040	0.040	0.2
Retrieval team costs - transport & consumables (up to)	0	0.085	0.085	0.085	0.085	0.340
SNOD costs (extra on call & transport costs) (up to)	0	0.029	0.029	0.029	0.029	0.116
Additional Retrieval & SNOD costs for non-proceeding donors (up to)	0	0.037	0.037	0.037	0.037	0.148
Total recurring	0.297	0.448	0.448	0.448	0.448	2.089
Grand total	0.627	0.494	0.448	0.448	0.448	2.465

Note – recurring costs are subject to a number of uncertainties and therefore are estimates only. In particular, costs for retrieval teams and SNOD on call and transport costs, along with the additional costs for non-proceeding donors, will be subject to negotiation with NHSBT and the other UK health departments. Based on NHSBT estimates for additional donors due to the opt out system, it should be possible to manage donation for these donors within existing resources. However, as previously noted, there would also be expected to be additional donors not resulting from the opt out system (due to other initiatives being undertaken). Therefore, when the additional anticipated donor numbers due to opt out are combined with other additional donors, there may be a need for additional funding as indicated in the table to cover the opt out costs.

Over the longer term opt out is expected to increase numbers of eye donors in Scotland in order to help meet demand. Currently Scotland imports more corneas from the rest of the UK for patients in Scotland than are provided by Scottish deceased donors – for example in, 2016/17, 282 corneas were donated in Scotland, but 338 corneal transplants were performed for patients resident in Scotland. However, other than training for staff (which is covered in the overall training costs for NHSBT) there are not expected to be additional costs associated with this as NHSBT charges hospitals for providing corneas for transplant on a cost recovery basis.

Scottish National Blood Transfusion Service ( SNBTS) ( Table 3)

SNBTS, part of NHS National Services Scotland, is responsible for retrieval, processing and storage of tissue in Scotland (excluding eyes for which donation processes are currently managed by NHSBT). The main tissue retrieved from deceased donors in Scotland by SNBTS is tendons and heart valves. SNBTS also receives deceased donor pancreata for processing into islet cells for transplant. The current supply of tendons is largely sufficient to meet demand in Scotland and therefore there are no plans to increase current rates of tendon retrieval. However, there is strong demand for heart valves, in particular pulmonary valves, as demand in Scotland is likely to increase in future. Therefore SNBTS would hope to work with NHSBT (as many tissue donors are also organ donors) to increase heart valve retrieval in Scotland.

Costs identified reflect the need for preparation for implementation

Table 3

	Year 1 2019-20 £ m	Year 2 2020-21 £ m	Year 3 2021-22 £ m	Year 4 2022 -23 £ m	Year 5 2023-24 £ m	Total £ m
*Staff costs and training -up to	0.062	0.118	0.118	0.231	0.231	0.76
*Test & Consumables - up to	0.009	0.018	0.018	0.036	0.036	0.117
Total	0.071	0.136	0.136	0.266	0.266	0.875

Assumptions

• Year 1- Staff costs - funding at 50% (assumes staff would be appointed mid-way through the year to allow for training and getting up to speed).
• Year 1-3 - 1 whole time equivalent ( WTE) Nurse band 6 for and increase to 2 WTE in Year 4
• Year 1-3 - 1.5 WTE Scientist band 6 for and increase to 3.0 WTE in Year 4

*Staffing and consumables costs will increase in accordance with activity

Costs of Transplantation

All solid organ transplant services in Scotland are nationally commissioned through NHS National Services Scotland's National Services Division ( NSD). Indicative targets for deceased and living organ donation were agreed between NHSBT and the four UK Health Departments until 2019/20. The indicative target to 2020 was 606 transplants for Scottish patients, for which funding is nominally allocated to Scottish units (funding for more rare types of or paediatric transplants carried out with Scotland is normally paid on a one-off basis to the unit carrying out the transplant). As noted, organs from deceased donors are allocated in a UK-wide basis. Therefore, while some organs from Scottish donors are allocated to patients living in Scotland, any increase in Scottish deceased donor numbers would not lead to a proportionate increase in Scottish transplant numbers as Scottish transplant numbers depend on deceased donor numbers across the UK as a whole. It is therefore unlikely that the introduction of a soft opt out system in Scotland would in the first few years result in transplant units exceeding 606 transplants for Scottish patients as this would require both a significant increase in deceased donors and the number of organs per donor which could be used. For example in 2016-17 there were 431 patients in Scotland who received transplants (348 of which were from deceased donors), although for planning purposes units were resourced to meet an estimated target of 527 transplants for Scottish patients (413 of which were anticipated to be from deceased donors). Therefore, while there is still significant work for units in preparing for deceased donor transplants which unfortunately do not proceed for a range of reasons, there should still be some capacity for units to increase the number of transplants carried out with current planned resourcing levels.

This will be reviewed in planning future transplant numbers and resource requirements beyond 2020 in preparing a successor to NSD's commissioning strategy 'Commissioning Transplantation to 2020 ^[29] ", particularly as other developments e.g. in other parts of the UK or in the use of novel technologies, have the potential to increase transplant numbers beyond the estimated additional transplant numbers due to the opt out system.

Similarly NHSBT, which co-ordinates organ retrieval for Scotland is funded to carry out more retrievals than currently take place, in line with the 2020 deceased donor targets. Therefore it is unlikely in the short term that retrievals will increase beyond the level currently funded and whilst these have been estimated for in Table 2 for year 2 they will be subject to negotiation.

Five Year Discounted Cost Projections based on potential impact of an opt out system of donation

The main costs surrounding the implementation of the soft opt-out system are derived from the need for awareness raising and education and from increases in resourcing costs for NHSBT and SNBTS.

It is assumed that, even for the baseline scenario, there would be an associated increase in costs from current activity, due to the fact that provisions in staffing would be made for implementation, even though these would result in no additional transplants (worst case scenario). The best estimate and higher estimate scenarios assume higher staffing and non-staffing recurring cost requirements associated with increased activity.

Total transplant costs were based on estimates on average costs per case provided by National Services Division of £61,956 per transplant. For the reasons set out above, we have not assumed additional costs for transplantation will result from the opt out system alone in the first couple of years. However, taking account of the fact that there are likely to be additional transplants not relating to opt out in addition to approximately 28 per year attributed to the opt out system, it is estimated that additional real terms funding may be needed from year 4 onwards to account for units being unable to increase transplantation further without additional resources. This will be discussed further with transplant units.

Total awareness raising and campaign costs were provided by Scottish Government and include media, public relations, production of promotion materials and other items.

Total evaluation costs include attributable costs of the Social Attitudes Survey and anticipated periodic costs for process evaluation, were supplied by Health and Social Care Analysis.

Future projections of costs were discounted at 3.5 ^[30] % to derive an overall estimate of Present Cost in years one to five. These range from £5.27m for the baseline, to £13.74 m for the best estimate, up to £22.54 m for the high estimate scenarios.

Baseline – no incremental change

Baseline estimate (low/now incremental change in transplants) £m	yr1	yr2	yr3	yr4	yr5	total non- discounted
	2019-2020	2020-21	2021-22	2022-23	2023-24	yr1-yr5
NHSBT - Total Non-Recurring Costs	£0.33	£0.05	£0.00	£0.00	£0.00	£0.38
NHSBT - Total Recurring Costs	£0.30	£0.30	£0.30	£0.30	£0.30	£1.48
NHSBT - Total	£0.63	£0.34	£0.30	£0.30	£0.30	£1.86
SNBTS - Staff total	£0.06	£0.12	£0.12	£0.12	£0.12	£0.53
SNBTS - Non-staff total	£0.00	£0.00	£0.00	£0.00	£0.00	£0.00
SNBTS - Total	£0.06	£0.12	£0.12	£0.12	£0.12	£0.53
Total transplant cost	£0.00	£0.00	£0.00	£0.00	£0.00	£0.00
Total awareness raising campaigns costs	£0.45	£1.41	£0.54	£0.43	£0.28	£3.09
Total evaluation costs	£0.02	£0.04	£0.03	£0.01	£0.00	£0.09
Annual total, non-discounted	£1.16	£1.90	£0.98	£0.85	£0.69	£5.57
Annual total, discounted at 3.5%	£1.16	£1.84	£0.91	£0.76	£0.60
Present Cost years 1-5						£5.27

Best estimate

Best estimate £m	yr1	yr2	yr3	yr4	yr5	total non- discounted
	2019-2020	2020-21	2021-22	2022-23	2023-24	yr1-yr5
NHSBT - Total Non-Recurring Costs	£0.33	£0.05	£0.00	£0.00	£0.00	£0.38
NHSBT - Total Recurring Costs	£0.30	£0.45	£0.45	£0.45	£0.45	£2.09
NHSBT - Total	£0.63	£0.49	£0.45	£0.45	£0.45	£2.46
SNBTS - Staff total	£0.06	£0.12	£0.12	£0.23	£0.23	£0.76
SNBTS - Non-staff total	£0.01	£0.02	£0.02	£0.04	£0.04	£0.12
SNBTS - Total	£0.07	£0.14	£0.14	£0.27	£0.27	£0.87
Total transplant cost	£0.00	£0.00	£0.00	£1.73	£6.94	£8.67
Total awareness raising campaigns costs	£0.45	£1.41	£0.54	£0.43	£0.28	£3.09
Total evaluation costs	£0.02	£0.04	£0.03	£0.01	£0.00	£0.09
Annual total, non-discounted	£1.17	£2.07	£1.15	£2.88	£7.93	£15.19
Annual total, discounted at 3.5%	£1.17	£2.00	£1.07	£2.60	£6.91
Present Cost years 1-5						£13.74

Higher estimate

High estimate £m	yr1	yr2	yr3	yr4	yr5	total non- discounted
	2019-2020	2020-21	2021-22	2022-23	2023-24	yr1-yr5
NHSBT - Total Non-Recurring Costs	£0.33	£0.05	£0.00	£0.00	£0.00	£0.38
NHSBT - Total Recurring Costs	£0.30	£0.51	£0.51	£0.51	£0.51	£2.35
NHSBT - Total	£0.63	£0.56	£0.51	£0.51	£0.51	£2.73
SNBTS - Staff total	£0.06	£0.12	£0.23	£0.23	£0.23	£0.87
SNBTS - Non-staff total	£0.01	£0.02	£0.04	£0.04	£0.04	£0.13
SNBTS - Total	£0.07	£0.14	£0.27	£0.27	£0.27	£1.01
Total transplant cost	£0.00	£0.00	£0.00	£3.66	£14.62	£18.28
Total awareness raising campaigns costs	£0.45	£1.41	£0.54	£0.43	£0.28	£3.09
Total evaluation costs	£0.02	£0.04	£0.03	£0.01	£0.00	£0.09
Annual total, non-discounted	£1.17	£2.14	£1.35	£4.87	£15.68	£25.19
Annual total, discounted at 3.5%	£1.17	£2.07	£1.26	£4.39	£13.66
Present Cost years 1-5						£22.54

Benefits

The positive health impact of receiving an organ can be measured in QALYs ^[31] . Patients who receive transplants on average benefit from longer life years and experience an improvement in quality of life relative to those patients whose conditions are managed with medical treatment. Following NICE methodology, one year of perfect health (equal to one QALY) is valued at £60,000.

The Welsh Government, in its impact assessment for the "Human Transplantation (Wales) Bill", used the following QALY values in their impact assessment. Multiplying these values by the value for 1 QALY year yields the following results:

Increase in QALYs gained from transplant
		£ value
kidney	4	£240,000
liver	13	£780,000
heart	7	£420,000
lung	4	£240,000
average	7	£420,000

*source: Scottish Government calculations and Welsh Government impact assessment

Using the average QALY figure as a maximum (i.e £420,000), we can then calculate the additional QALY values for the additional number of transplants as follows. These range from £0 for the baseline, to £45.33m for the best estimate, up to £95.51m for the high estimate scenarios.

It is important to note that these estimates of benefits are non-cash releasing and are a monetary representation of the value of a life saved, extended or improved only.

Baseline – no incremental change

Baseline estimate (low/now incremental change in transplants)	yr1	yr2	yr3	yr4	yr5	total non- discounted
	2019-2020	2020-21	2021-22	2022-23	2023-24	yr1-yr5
Total QALYs gained	0	0	0	0	0
Total QALYs, years 1-5	0
QALY monetary value (£m)	£0	£0	£0	£0	£0	£0
QALY monetary value, discounted at 1.5% (£m)	£0	£0	£0	£0	£0	£0
Present Value, years 1-5 (£m)						£0

Best estimate

Best estimate	yr1	yr2	yr3	yr4	yr5	total non- discounted
	2019-2020	2020-21	2021-22	2022-23	2023-24	yr1-yr5
Total QALYs gained	0	196	196	196	196
Total QALYs, years 1-5	784
QALY monetary value (£m)	£0.00	£11.76	£11.76	£11.76	£11.76	£47.04
QALY monetary value, discounted at 1.5% (£m)	£0.00	£11.59	£11.41	£11.25	£11.08	£45.33
Present Value, years 1-5 (£m)						£45.33

Higher estimate

High estimate	yr1	yr2	yr3	yr4	yr5	total non- discounted
	2019-2020	2020-21	2021-22	2022-23	2023-24	yr1-yr5
Total QALYs gained	0	413	413	413	413
Total QALYs, years 1-5	1,652
QALY monetary value (£m)	£0.00	£24.78	£24.78	£24.78	£24.78	£99.12
QALY monetary value, discounted at 1.5% (£m)	£0.00	£24.41	£24.05	£23.70	£23.35	£95.51
Present Value, years 1-5 (£m)						£95.51

Additional benefits from theatre use and workforce productivity

Theatre productivity

Additional benefits can be assumed to be derived from increased efficiencies in theatre throughput if an increase in available organs results in an increase in the successful delivery of organs for transplantation.

The analysis assumes that these benefits will take effect from year 3 onwards – with years 1 and 2 absorbed by existing capacity. The benefits represent a non-cash release of productivity improvements as expressed by the proportionate inverse of the surgery cost.

Whilst this is an estimate of the potential productivity benefits, there are multiple influencing external factors, such as staff rota and the baseline theatre capacity and operating schedules which will impact on the exact outcomes for theatre productivity.

Baseline – no incremental change

Baseline estimate (low/now incremental change in transplants)	yr1	yr2	yr3	yr4	yr5	total non- discounted
	2019-2020	2020-21	2021-22	2022-23	2023-24	yr1-yr5
Total productivity improvements in theatre utilisation	£0.00	£0.00	£0.00	£0.00	£0.00	£0.00
Present Value, years 1-5 (£m)						£0.00

Best estimate

Best estimate	yr1	yr2	yr3	yr4	yr5	total non- discounted
	2019-2020	2020-21	2021-22	2022-23	2023-24	yr1-yr5
Total productivity improvements in theatre utilisation	£0.00	£1.68	£1.62	£0.00	£0.00	£3.30
Present Value, years 1-5 (£m)						£3.30

Higher estimate

High estimate	yr1	yr2	yr3	yr4	yr5	total non- discounted
	2019-2020	2020-21	2021-22	2022-23	2023-24	yr1-yr5
Total productivity improvements in theatre utilisation	£0.00	£3.53	£3.41	£0.00	£0.00	£6.94
Present Value, years 1-5 (£m)						£6.94

Workforce productivity

At a societal level, there can also be assumed to be gains in productivity if recipients of successful organ transplants are able to contribute economically for an increased duration after the operation. Again, multiple factors, such as the age of the recipient and the capacity for employment will play a role. Detailed information on transplant recipients' employment is limited, and therefore has not been included in the costings. However one study has reported that approximately 80% of organ transplant recipients in developed Western Europe are able to return to full-time employment after a successful operation ^[32] .

Net Present Values

Having estimated the discounted costs and benefits, we can now estimate the Net Present Value ( NPV – the difference between Present Benefits and Present Costs). A positive NPV indicates that the benefits outweigh the costs. For the baseline (worst case scenario), the NPV is negative, as there are assumed increases in costs due to implementation, with no additional benefit from increased number of transplants.

Both Best estimate and higher estimate scenarios are net positive.

Summary Costs and benefits: Net Present Values (NPVs) £m	Baseline estimate (low/now incremental change in transplants)	Best estimate	High estimate
Present Value (PV), years 1-5	£0.00	£45.33	£95.51
Present Cost (PC), years 1-5	£5.27	£13.74	£22.54
Net present Value (PV-PC)	-£5.27	£31.58	£72.97

Including Theatre productivity

Summary Costs and benefits: Net Present Values (NPVs) £m	Baseline estimate (low/now incremental	Best estimate	High estimate
Present Value (PV), years 1-5	£0.00	£48.62	£102.46
Present Cost (PC), years 1-5	£5.27	£13.74	£22.54
Net present Value (PV-PC)	-£5.27	£34.88	£79.92