Medical and social development of the English and Welsh Blood Service
The evolving status of venepuncture – by Tim Sandle
My thesis aims to examine the social and medical development of the Blood Service of England and Wales, with a focus upon the job roles and occupational skills of its medical and non-medical staff. The thesis begins with the origins of the Blood Service in the 1920s and continues the examination into the early 2000s when the service merged with other services specialising in organ donation and plasma products. One of the key findings, which has implications for other medical skills and technologies, is how such skills are ‘devalued’ by being passed through occupational hierarchies.
The Blood Service of England and Wales was established as a large-scale healthcare service in World War II, and then expanded considerably as the National Blood Transfusion Service, part of the newly created NHS. The origins of the service can be traced back to Camberwell, London. In 1921 the British Red Cross, at the initiative of Percy Lane Oliver, ran a blood donation session at King’s College Hospital. For this pioneering transfusion the veins of the donor were cut open to extract blood and then tied back together. From this beginning, Oliver established a London-based mobile service, which increased activity from 13 donations in 1922 to 428 in 1925. Later, in 1937, the first permanent blood bank was opened in Ipswich. These plans were advanced during World War II, when the high casualty rate increased the demand for blood and technological developments led to blood collections becoming possible on a larger scale. The Blood Service grew rapidly during the 1950s, fuelled in part by advances in new surgical techniques such as open-heart surgery, which increased the demand for blood, and by 1966 the number of registered blood donors surpassed one million for the first time.
While the scope of the operations of the Blood Service involves a wide range of serum and tissue work, its key purpose is the collection of blood from donors. Here whole blood (red cells) is collected from donors by a specialist technique called venepuncture, whereby blood is removed through the antecubital fossa in the elbow using a needle and is transferred into a specially designed plastic bag. The amount of blood collected per donation is one ‘unit’ (equivalent to 450 millilitres, usually collected within ten minutes and representing around 13 per cent of the total blood volume in the average human body). Collected blood is transferred to a blood bank for purification (cell separation), safety testing and the addition of chemicals, which extend the expiry time to 28 days.
From the research in the Blood Service one of the most interesting historical processes is the change to occupational skills and the transfer of some skills downwards through the occupational hierarchy. This was most notable in terms of venepuncture, and the historical change in the status of this skill appears inversely related to the increase in blood donations and expansion of the workforce.
Before the 1950s, blood transfusion was undertaken on a relatively small scale. The blood collection process was very labour-intensive and the donation processes were administered by physicians, with nurses in a support role backed up by volunteers. Despite the heavy reliance on volunteers, the majority of the tasks undertaken – blood collection, processing and transfusion – required the use of relatively sophisticated medical techniques. During the 1930s and 1940s a typical blood collection session dealt with four donors at a time and 12 donors a day. The staffing requirements were typically for one doctor, four nurses, two receptionists (ancillary nurses), one general assistant and one driver. The presence of a doctor, absent from blood collection sessions today, reflected the relatively high chance of adverse reactions occurring, as well as being indicative of a rigid demarcation of roles. The class and gender basis of the role separation of doctors, who were predominantly male, and nurses, who were near universally female, is reflected in the medical textbooks, journals and monographs of the time (such as the nurse in a ‘subservient role’ and even being on hand to supply Bovril to donors). Even by 1954 the training manual for a transfusion nurse stated that when collecting blood all unusual observations must be immediately notified to a doctor. Despite the hierarchy of occupations, the consensus of the medical texts was to describe the work of the donor collection teams as ‘skilled’.
Postwar, as blood collection and transfusion became more widespread, the labour-intensive and routine nature of the role became less attractive to the medics who had previously monopolised the ‘scientific technique’ of venepuncture. In the 1930s, venepuncture was regarded as highly ‘skilled’ and the preserve of doctors. In a process of engendering, skill revaluation and substitution, blood collection tasks such as venepuncture were transferred down the occupational hierarchy to lower-paid registered nurses. This act of substitution was undertaken by reclassifying venepuncture from a (chiefly male) ‘medical skill’ and recategorising it as a (feminised) ‘nursing’ task. As the demand and application of blood and blood products grew considerably in the 1970s a second transfer of the task of venepuncture occurred.
The expansion of blood collection required significantly greater numbers of workers to be hired. This led to the creation of an ancillary nurse role described as a Donor Collector (later Donor Carer). The relationship between the registered nurse and the Donor Carer is similar to the occupational division between registered nurses and Health Care Assistants seen within hospitals. To facilitate this, venepuncture was reclassified as a lower-valued ‘technical’ task with its absorption into the duties of Donor Carers. With this displacement down the occupational hierarchy, the complexity of the task did not alter, still requiring a detailed knowledge of biology and physiology.
What is significant from the historical analysis is not simply how occupations alter over time but also how professional groups interact in terms of role demarcation and how employers achieve wage bill savings by reallocating tasks from higher-paid staff to staff at lower grades. The consequent increase in the numbers of lower-paid workers at the expense of higher-paid occupations allows the total wage bill to be reduced (inherent within employer strategies are ideological assumptions about the relative fairness of the pay structure). The redefinition of a grade is often associated with increasing the workload.
Often in sociological literature, task changes between occupations is described as ‘deskilling’. The concern with the term deskilling is that it undervalues the skills of lower-graded posts, which are often not dissimilar to the higher-paid posts. Sometimes new technologies can enable a task to done with less ‘skill’, but not always. With the example of venepuncture, the task remains as ‘skilled’ today, performed by some of the lowest-paid staff in the NHS, as when practised by the medics who bestrode the top of the occupational wage hierarchy. There are also wider implications in terms of social divisions, for jobs heavily populated by women are most commonly the lowest paid, as are those that are not considered to be classed as a ‘profession’. Thus the case of venepuncture locates the historical evolution of occupations in both a medical and a social context.
Tim Sandle is a part-time PhD student at Keele University.