Tuesday, 9 December 2014

Liverpool Care Pathway - AC/DC

Advanced Care...
or Directive to Care less?

The old, the vulnerable, are not a nuisance but an opportunity to care. To care is a privilege.
Liverpool Care Pathway – A Loss Of Touch With the Final Reality Of Life
Disability is also a badge of pride the bearer may shame us with the merit of their courage and achievement.

Caring may humble the haughty and punish the proud. Caring ennobles the soul.

Do not raise complaint, but give thanks. To care is not a chore but a privilege and an honour bestowed upon us.
Say it loud, say it clear,
For the whole wide world to hear:
"Thankyou for enabling me to care."
[With apologies to The Lighthouse Family]
If we cease to care then we cease to be human.

The manner in which something is put may change its meaning entirely. Just as the ‘right’ to die may permit the right to kill, so a Directive to deny treatment may just simply confirm and justify its withdrawal.

The Directive imagines scenarios in which the Director decides they would prefer the ‘remedy’ for the ill or the protocol for treatment should not be applied. These are scenarios considered to be untenable but when the alternative is death is there an alternative? Doctors have means enough already to come to a determination to deny treatment and to deny life.

The Mental Capacity Act of 2005 permits doctors to act in the patient’s “best interests” and withhold all treatment when it has been adjudged that they are incapable of taking decisions for themselves. This includes withholding food and water as this, also, is a medical intervention.

This is a determination that it is in the patient’s "best interests" to die.

If families try to intervene to save their loved ones lives, social services and police can be, and have been, called to intervene.

The ACD will only make this decision easier for doctors to take and relieve them of all responsibility. In other words, let them off the hook, both morally and legally.

Barbara Wilding, Britain's longest serving female chief constable, commented that the growing public approval for ‘assisted suicide’ is a threat to elderly people and that "a growing rift" between the generations is becoming a significant challenge for police who are concerned that a relaxation of the law could be exploited by families to kill "burdensome elderly relatives".

The ACD provides the means. A Donor Codicil provides an incentive.
The key issue is that there are numerous clinical situations which mimic the dying phase, including dehydration. The hospice movement in Britain continues to teach that rehydration via a drip is rarely necessary – despite evidence from America to the contrary – and that the use of a drip "medicalises dying".

Dehydration can cause the build-up of toxic metabolites from morphine and other drugs, resulting in confusion, drowsiness and jerking or twitching. This is then often managed by sedation rather than rehydration.

When I last audited my use of intravenous rehydration in a hospice setting, 50 per cent of the patients went home – which invites the question of what happens to patients in those hospices which still refuse to offer rehydration.

The answer perhaps lies in the disturbing number of deaths in Britain following continuous deep sedation.

Dr Peter Hargreaves
Patient confidentiality

The relationship between doctor and patient has always been a special one, guided by the Hippocratic Oath, by honour, integrity and common decency. Did all that begin to go awry with the intervention of the State to create a socialised medicine? Or was it never so?

Yevgeny Zamyatin forewarned in 1924 with the publication of ‘We’, for there is only Us and everyone counts.

George Orwell warned in ‘1984’ of a Big Brother, an Auntie State intervening in every aspect of life.

Big Brother is a public guardian who knows better than we what is best for us and will take charge of us and our affairs for our own good. 1984 was 30 years off the mark and we are walking into Big Brother's world with a smile and a grin to welcome him with arms open wide.

A reality has spawned in 2014 of secret courts that mete out judgements behind closed doors and sit for our ‘protection’. Newspeak is rife and, everywhere, it is all for ‘our own good’ that we willingly submit and accept and, soon, shall leap with joy onto the Carousel, to be conveyed off into oblivion.
Liverpool Care Pathway - Data Is Power
The Health and Social Care Act 2012 affected the ways in which NHS organisations can access and process data.

During the opening weeks of 2013 came a snatch and grab of confidential patient records uploaded to a central databank.

Everyone Counts had arrived...

All NHS funded providers (including independent sector) are required to comply with data collections to a central bank, the HSCIC (Health and Social Care Information Centre).

In Primary Care, data sets developed with the help of the CCGs will be extracted from GP practices for submission. ALL patient data, including ‘identifiable components’, will be sourced and stored utilising the centrally funded General Practice Extraction Service (GPES).

Fear not citizen, the GPES is a ‘secure’ Database. The HSCIC is a ‘safe haven’. There is no exception. All data is stored...
NHS England

NHS Number
Date of Birth
Post Code
Ethnicity Code
Registration Status
Registration Date
DeRegistration Date
Date of Death

Diagnosis, referral and event data, even dietary and exercise advice are recorded.

General Practice Prescribing Data will be collected through the Electronic Prescription Service.

Pathology data will be collected through results messages sent by laboratories.

The way people are cared for and treated is being “radically transformed”. The patient is no longer the patient but part of the group. This is essential to gather and identify candidates for the lists which GP’s were also asked to draw up in 2012, the so-called 1% which some have dubbed ‘Death Lists’.

The identified patients are earmarked for downsized care. This is the patient ‘toolkit’ launched by Norman Lamb. Doctors are expected to pick out patients during routine consultations that show ‘indicators of frailty and deterioration’ and are told that ‘older people are a priority to consider’.

District nurses and hospital consultants feed back information. Patients in care homes are ‘actively considered' for the register.

Using GSF and the Barton Method, GPs identify those 'at risk' of being admitted to hospital. The GP computer system EMIS Web also identifies patients who are most likely to require an unplanned A&E admission and those with ‘multi-morbidity’.

These patients are ‘less likely to be subject to treatments of limited clinical value’.

This will save the NHS £billions each year.

This is risk stratification. You can’t dig your way out of a hole; you have to fill it in. Cutting ED attendance is key and identifying the ‘one percent’ is the combination to the lock.

PCC risk stratification
NHS England has today published advice on how to conduct risk stratification while complying with the new legal framework that exists following the implementation of the Health and Social Care Act 2012.NHS England
The Health and Social Care Act 2012 changed the levels of access to data for different commissioning organisations. This caused "significant" concerns. A NHS England Information Governance Transition Programme will “develop a range of short-term and medium-term measures to address these issues”. The Programme will also “identify the longer-term requirements to ensure that users of data within the NHS are able to access the data they need to undertake their roles in a timely, cost-effective and legal manner”.

The Act complicated the legal landscape relating to risk stratification.
Risk stratification tools typically use historic information such as age, gender, diagnoses, and patterns of hospital use as the basis of their predictions. Some models (e.g., PARR and PARR-30) use a combination of hospital data and geographical data such as the Index of Multiple Deprivation. Other models (e.g., the Combined Predictive Model) use primary care data derived from GP practice systems in addition to hospital data as the basis of their predictions.
The legal framework governing the use of personal confidential data in health care is a maze of various Acts and Regulations. These include the Health Service (Control of patient information) regulations 2002, the NHS Act 2006, the Health and Social Care Act 2012, the Data Protection Act, and the Human Rights Act.

NHS England sought and obtained transitional support under the Section 251 regulations for a period of three months for the Section 251 support previously provided to PCTs. In addition, CCGs were established as Accredited Safe Havens (ASHs) of information.

In the following letter, use of ‘pseudonymised data’ and ‘weakly pseudonymised data’ in an Accredited Safe Haven is discussed...

Hunt wants millions of private medical records to be stored and shared between hospitals, GPs, Care Homes and local councils. This is Everyone Counts: Planning for Patients 2013/14, a programme designed to extend the availability of patient data across the health service, controlled by the NHS's Health and Social Care Information Centre.

What Labour began, the Coalition has expanded upon.

Simon Stevens' Integrated NHS is already in the making.

NHS England
Data and information pooling is key. This is ‘Co-ordinated Care’. Risk assessment coupled with co-ordinated care reduces admissions. GPs, hospital and community nurses, social carers and mental health professionals all ‘securely’ share vital medical information (with patient permission) to deliver care that ensures no-one falls through the net and ends up in hospital.

Risk Assessments are formulated also sourcing available ACDs.

Beware what you wish for.

Autumn 2014 and Care Dot Data is back with a phased roll out involving up to 500 GP Practices...
In recent months, NHS England has heard from GPs, professional bodies and patient groups that more needs to be done to ensure that patients and the public have a clear understanding of NHS England’s intention to use patient data held by GP practices for purposes beyond direct health care. In particular, greater assurances are sought on issues such as patients’ right to object, protecting privacy, the burden on GPs, and the controls around how data held by the Health and Social Care Information Centre (HSCIC) will be accessed and used.

This is why NHS England announced an extension to the proposed roll out of the care.data programme, until the autumn, to raise awareness, listen and act on the views of patients and key stakeholders, and to discuss both the benefits and risks involved. More discussion, debate, reassurance and action is needed around issues such as ensuring the public are aware of their choices and are empowered to take informed decisions based upon a clear understanding of the issues. See here for details of how to get involved in forthcoming discussions about the care.data programme.
The pressure cooker is bubbling -
- London Evening Standard
With an aging population increasing demand for local services, London Councils maintained that boroughs in the capital will be underfunded by £3.4 billion by 2020.

‘Many councils will be forced to cut to the bone if the Government continues to make these levels of annual cuts up to 2020’ - Jules Pipe, Chairman of London Councils

They are ‘halfway through the cuts’.

And we are only half way there...
Liverpool Care Pathway - Active Killing...?

Liverpool Care Pathway - In The Beginning Was The Pathway...

This is the cost of living. The reckoning is coming.

Tuesday, 2 December 2014

Liverpool Care Pathway - Back To A Way Forward

Desperate times, desperate attitudes and desperate people: A shame on our house...

To stand by and do nothing while a wrong proceeds unchallenged is to be complicit in it. Complacency permits the unthinkable to become thinkable and the unacceptable to become possible.

A culture-shift has taken place, in the NHS, in attitudes and perceptions, across all levels. Call it spin, call it what you will, this is social engineering...

Liverpool Care Pathway - Nudge, Nudge, Say No More...
The culture-shift is planned and is proceeding...
Liverpool Care Pathway - The Bee Wee Consultation

Just make it sound desirable...

The Advance Directive has been advanced by Euthanasia 5th Columnists in Age UK and has spread into Local Government and Social Housing...

New paperwork is being introduced at our scheme...

The Advance Directive is now included to source information for risk assessments. This will impact in ways unthought-of and unforeseen upon those who have agreed or been persuaded to make them.

The fundamental instinct to rescue life is being challenged.

Whatever happened to: "Never say die!"?

Whatever happened to: "Where there's life, there's hope!"?

The Guardian reports on an Office of National Statistics finding that a fifth of certified causes of death are inaccurate.

They cannot get it right after the fact. How can they get it right up to a year before the fact?

Would you rather be a hammer or a nail...?
Liverpool Care Pathway - The Nail In The Coffin
Liverpool Care Pathway - The Shadows That Precede
Doctors are encouraged to approach the patient not with trust and hope but as a predator seeking its prey to find their one percent.

Diseases may follow clear, definable illness-trajectories; patients do not.

Even for those with a terminal illness, there are no certainties. It is for this reason that every medical practitioner should despair of the Government's policy to identify and to hunt down their ‘one percent’ for palliative care.

This is a fundamentalist Communitarianism that aims to assess the likelihood of death in patients within a time frame of one year, whatever their diagnosis. The Barton Method to ‘eye them up’, as defined in the Gold Standards Framework, is recommended for this purpose.

Patients are being treated as falling into a category rather than as individuals. Certain classes of patients are being treated like starfish left high and dry at low tide.

If they survive until the tide turns again, then...

But no effort will be made to throw them back into the water. When there are so many and such finite resources to cope, it is clear where the Communitarian line must be drawn.

Doctors used to enter their profession with an awe and a wonder at the resilience of life to fight back and to cope; armed with a respect for life defined by the Hippocratic Oath, they knew that life is precious and living matters.

The London Evening Standard reports on a 'study tour' by a delegation from Imperial NHS Trust to the East Coast funded by the DoH -

Ann Drinkell of the Save Our Hospitals Campaign responded: “I think we don’t want the American model of care, which is based on the ability to pay – not on need.”

Actually, what care or treatment is allocated to you is based not on need but a mathematical calculation.

N.I.C.E. employs a template of criteria based on "efficacy and cost effectiveness," in which a key formula is the "quality adjusted life year" (QALY). The QALY "takes into consideration the quality of life of the patient during any additional time for which their life will be prolonged". The clinical and cost effectiveness of the treatment is then used as the basis for a recommendation as to whether or not the treatment should be provided.

Other aspects of the N.I.C.E. criteria include the concept of the "cost per quality adjusted life-years gained" (CQG). The CQG examines the cost of treatment, divided by the estimated years to be gained by the treatment and creates an "overall cost benefit ratio", giving the "cost per quality adjusted life-year gained". Under this criterion, cancer treatment for a small child may deliver many more years of "quality of life" than the same treatment on an elderly patient.

'Quality of Life' is a dangerous expression. Can it be determined and is it determinable? It places those with disability at risk in a society that demands DNR decisions and may yet inflict 'assisted suicide'.

A NHS policy team has been sent to the US.

Policy sharing has proceeded and is proceeding.

The NHS is in dire financial straits. Likewise, Medicare and Medicaid are not sustainable. Both those of this and those of that political ilk each lay blame and accusation at each other's door.

Affordable healthcare does not mean making healthcare affordable but cost-effective. It means making it affordable by limiting available healthcare options.

Obama advisor,Cass Sunstein, has written in support of what some people have called the "senior death discount" which is the statistical practice of taking into account years of life expectancy when evaluating a regulation. This is key to the fundamentalist Communitarian thinking of Obamacare.

Fittingly, Sunstein has repeatedly and consistently defended the idea of a strong regulatory State. He has turned his back on the constitution of the Founding Fathers to secure the people from the State and adopts the European model.

Catch-up reading -
Liverpool Care Pathway - The Micawber Principle 
Liverpool Care Pathway - Crying Wolf 
Liverpool Care Pathway – The Protocol Of Choice
The individual doctor has always responded by treating the individual patient before them, traditionally, according to the Hippocratic Oath.

No more...

The patient is categorised and responded to accordingly rather than responded to according to the medical demands of the individual patient. The protocol of the category is easier to respond to; it is 'less fuss', less time-consuming and with 'evidenceable' outcomes.

A protocol pertaining to category removes responsibility and releases the medical practitioner from tiresome, time-consuming responsive diagnosis. The physician's time is more efficiently and economically spent.

Nothing is 'free'. Even something for which there is 'No Charge' requires the free-given effort of the charitable giver, and, let’s be clear about this, the NHS is not ‘free’. Like everything else, it has to be paid for. For some, it’s a rip-off they are paying for twice over –

Liverpool Care Pathway – Another 'National Scandal' 
Liverpool Care Pathway – By Fault, Or By Default And Design? 

Policy and design are being pooled and shared as they get back to a way forward.

According to Mr. Hunt, Local government has been squeezed by ‘tough financial settlements’.

This is HSJ –

The NHS has a responsibility to help local authorities cope with their “tough financial settlement”, health secretary Jeremy Hunt has said. 
Mr Hunt made the comments in a speech at the National Children and Adult Services conference in Manchester yesterday, according to HSJ’s sister title Local Government Chronicle.
“We prioritised the NHS by protecting its budget, which meant tougher settlements for other departments including local government,” he said.
“But the interconnected relationship between the services we both offer to vulnerable people means that we in the NHS have a responsibility, as we move to fully integrated services, to help you [in local government] deal with a tough financial settlement.

Mr. Hunt was talking about the £5.3 bn Better Care Fund to keep people out of hospitals. Health and Wellbeing Boards have been created and local authorities have been charged with greater responsibility in this area.

The Health and Wellbeing Boards have been productive in developing EoLC provision and the move to ‘respecting and acting upon’ EoL wishes - code for Advance Care Directives.

The Fund is to further enable this process.

According to the The King's Fund, the Better Care Fund has been implemented in the context of an aging population. This is spending money not to provide for demand but to reduce that demand. This is spending money to save money -
As financial and service pressures facing the NHS and local government intensify, the need for integrated care to improve people’s experience of health and care, the outcomes achieved and the efficient use of resources has never been greater.

The June 2013 Spending Round announced the creation of a £3.8 billion Integration Transformation Fund – now referred to as the Better Care Fund – described as ‘a single pooled budget for health and social care services to work more closely together in local areas, based on a plan agreed between the NHS and local authorities’ (Local Government Association and NHS England 2013).

The £3.8 billion is not new or additional money: £1.9 billion will come from clinical commissioning group (CCG) allocations (equivalent to around £10 million for an average CCG) in addition to NHS money already transferred to social care. For most CCGs finding money for the Better Care Fund will involve redeploying funds from existing NHS services. Guidance makes clear that the Better Care Fund will entail a substantial shift of activity and resource from hospitals to the community – ‘hospital emergency activity will have to reduce by 15%’ (NHS England 2013). This could place additional financial pressures on providers already facing the quandary of how to maintain and improve quality of care while achieving financial balance. In addition, the Better Care Fund does not address the financial pressures faced by local authorities and CCGs in 2015 which ‘remain very challenging’ (Local Government Association and NHS England 2013).
The King’s Fund says that the Fund consists of £3.8 bn of reallocated money.

The National Audit Office announces that the Better Care Fund will pool £5.3 bn of existing NHS and local authority funding and will run from April 2015.

What has happened?

Public Finance  explains -
Hunt said yesterday that there had been ‘remarkable progress’ in the development of the fund plans, which would be the first time anywhere in the world efforts had been made to integrate health and social care across an entire health economy.

‘Building on the excellent work by [care minister] Norman Lamb on the Integration Pioneers that many of you were involved in, local authorities and local NHS commissioners have joined together and painstakingly planned commissioning for adult health and social care with pooled budgets,’ he said.

‘Budgets from the local authority side are for the first time helping to reduce emergency hospital admissions and budgets from the NHS side are for the first time helping to reduce permanent admissions to care homes.’

He said that critics who had said the initiative was unachievable had been proved wrong, ‘because today I am delighted to announce the total amount of pooled budget for next year is even higher than the government’s original £3.8bn – it has risen to a staggering £5.3bn’.

He said that 146 of the 151 plans have been approved, with additional help being offered to the five remaining areas.
HSJ continues -
During the speech Mr Hunt said there would be “no sustainable future for the NHS without a sustainable future for social care” and there would be “no sustainable future for social care without a strong NHS”.
Mr Hunt said the fund, a £5.3bn pooled budget between councils and the NHS to join up health and care services, was “not peripheral, but central to the kind of change we want to see in our NHS and social care system”.

The Five Year Forward View published jointly by NHS England in October reflects these changes, speaking of new partnerships with local communities and of closing the projected budgetary deficit in whole or in part by 2020/21.

In response to this, the Chancellor, George Osborne, has promised increased funding, a third of which is, again, reallocated money.

The Terminator

Simon Stevens is back...

This is NHS England –
It’s good to be back – back in the NHS, and back here on Tyneside.
I know times are tough, and the Health Service is under pressure. But when people ask me why take on this new job? My answer is:  Because I believe in the NHS, and I believe in its future. That it will be there when we need it, at the most profound moments in our lives. At the birth of our children. At the deaths of our loved ones. And at every stage in between – as we grapple with hope, fear, generosity, loneliness, compassion – all the most profound elements of the human spirit.
I was reminded of this again this morning in Consett, County Durham, where 26 years ago I started work in the NHS. Obviously the hospital has changed a lot – the old Nissen hut wards are long gone, and services have moved. But the nurses and patients and GPs I chatted with on the cancer unit and rehab service had that same passion and commitment for health, and made a convincing case that the quality of care is better than ever.
And Simon has been generously welcomed back...

Polly Toynbee heaps praise in The Guardian –

Toynbee praises Stevens’ plan for its good ideas.

Toynbee writes -
Stevens’s opening eulogy to NHS principles has a passionate ring, and that’s the way he talks about the service too. He likes to quote the US Commonwealth Fund, a private health foundation and his only outside board, whose annual research puts the NHS at or near the top as the most effective, best bang-for-the-buck service in the world.
That’s no mean praise from stage left.

Clearly, the same aggressive policies of downsized healthcare provision shared by Obamacare and NHS in the pursuit of fundamentalist Communitarian policies will continue as the ‘best bang-for-the-buck’ measure to deal with the multi-morbidity ‘Tsunami of need’ referred to in the End of Life Baseline Report.

Pertinent reports -
Liverpool Care Pathway - The Communitarian Nudge

Liverpool Care Pathway - Appointment With Death
Downsizing care expectations and accepting the glass as half empty is key.

Simon knows he can make that difference...

Stevens describes the NHS as a 'social movement'. That means what it implies and Stevens' manifesto is - in Obama terminology - a living document.

Stevens understands that he is looking into the economic abyss. At such times, the audacity of hope becomes the audacity of desperation. The Communitarian demands of altered standards of care and rationing of available resources must be employed and presented favourably in a manner such that they will be accepted.

Final words -
Liverpool Care Pathway - What Prospect Does This Bode...?

Liverpool Care Pathway - The Communitarian Imperative

Liverpool Care Pathway - Living Wishes

In the Margins

The Mail reports our old ones marooned and abandoned so their families may finish their decorating and go on holidays.

The Mail reports that a ComRes poll actually found that 10% of people thought the sick and elderly should be rewarded for ending their lives. A quarter were undecided...

This ‘Tsunami of need’ is unwanted, a hindrance, a burden of bed-blockers.

In The Margins

Tuck me in
I need to sleep now
I need to dream how
I used to dream

Look me in
Look me in the face now
Help me believe how
I used to believe

Now do you see how
They're in the margins
Below and up above
I'll see now
How life wins
When all that's left is love

- Echo and The Bunnymen

Tuesday, 25 November 2014

Liverpool Care Pathway - A True Story: The Next Generation

Is this a war of attrition that we wage, against an enemy insidious in its cunning...?

These pages reported last year a true story.

The story, The Big Kill, was related - for benefit of those too young to remember - in the style of the US 50’s wireless and tv serialisation, Dragnet. Only the names were changed to protect the innocent.

The Overkill -

What follows is also a true story. It is the story of May’s daughter, Jane. Her name, also, has been changed for she, also, is numbered among the innocent...

Jane is now undergoing chemotherapy in the very same hospital that took her mother’s life.

While fighting her own good fight with cancer, Jane continues to fight the good fight for her mother with the PHSO. This is proving to be a farce.

Jane’s case for her mother – after all these months – is still no further forward. In fact, it is at a standstill. The PHSO have responded, as they must to accord with their Mission Statement, but no action has thus far been undertaken.

The case is plain and clear. Permission had to be obtained from the patient to proceed and it was not. Why has not Jane’s case for her mother, then, proceeded?

The PHSO lacks the staffing capability.

What does this say then, about the NHS if the PHSO are so inundated with complaints that they do not have the staff to deal with the volume of complaints?

What springs to mind is our correspondence and dialogue with the CQC.

Particular reading -
Liverpool Care Pathway – The Audacity Of Hindsight
In 2011, the CQC Inspector informed us that there were budgetary constraints on the CQC and that at that time investigations were focussed on care of the elderly. I pointed out that such investigations could also incorporate investigation on the use of the LCP. Mr Jenkins acknowledged what I said but did not hold any hope of such a proposal being accepted.

Budgetary constraints.

It was not until November of 2012 that the ineffectual Review was announced by Norman Lamb. This was at the threshold of a brand new year, 2013, and only following a hard-hitting campaign by a national newspaper, which had itself been vilified for undertaking such a campaign!

Budgetary constraints. Is this why Jane’s case may not proceed?

Lord Carlisle
 called for doctors who put patients on the LCP without their permission to be struck off.

There are a multitude of them! Have any been even hauled before the GMC, let alone been struck off?

Jane is attending the chemotherapy suite three times a week. Last week, she had to attend early to send off her bloods.

Jane arrived at 11 a.m. quite prepared for the long wait that proceeded. At the county hospital where the cancer drugs are prepared, they had to get the dose right. It was a long wait, but the preparation is key to treatment.

At 4.30 p.m., the drugs arrived in the chemotherapy suite. The requisite checks were completed and the drip for the infusion was set up.

On Monday, I accompanied a client to the local pharmacy. I am in the habit of acquiring useful and appropriate leaflets for the scheme and one caught my eye –

The infusion was less than half complete when the line was removed and a saline bag set up to flush her through. It was approaching 6.00 p.m. and they were impatient to get off home to their dinners.

Jane was given her antibiotics but no Piriton. The uncomfortable reaction she gets manifests upon completion of treatment and this point was nowhere near.

Could no-one have stayed with her to complete the infusion? The drugs will not ‘keep’ and are specific to her treatment.

Apparently not. Previously, Jane has been sent through for observation to the ED when the reaction has been severe.

What means this grand reputation? Their purpose was persistent and present in the grooming of May’s family and the taking of May’s life...

Are we blinded by the light?

These drugs were thrown away. That was not good for Jane: she did not complete her treatment!

These drugs were thrown away. That was not good for the NHS: cancer drugs are notoriously expensive!

Jane's daughters have been attending with her and the strain has taken its toll with them, also.

The story so far -

Liverpool care Pathway - A True Story 

Liverpool care Pathway - A True Story Supplemental

Liverpool Care Pathway - Responses Will Be Answered
Additional reading -
Liverpool Care Pathway - On Pint-sizing Perceptions of Care And The Betrayal Of Trust

Liverpool Care Pathway - Self-Accreditation...?
Do they cast a glamour, do we walk in thrall that we are blinded by it all? 
Yea, though do I walk unto the glamour of the Spectacle, thine Brand and thine Image shall comfort me all my days!