Liverpool Care Pathway - A Rationing Of Care

Patient Protect is

an organisation dedicated to the prevention of neglect and incompetence in our National Health Service, and to the elimination of the secrecy which allows these problems to flourish. "Sunlight is the best disinfectant"¹

This is from the Patient Protect website. The subject matter is hauntingly close to and parallels and mirrors the content produced in these pages: 

Most patients enter hospital with the belief that they will be treated by competent staff, and that they will receive whatever treatment they need in order to achieve a successful outcome.  The Patients’ Charter, recently abolished by this Government, actually stated that these beliefs amounted to a right, presumably protected by the Government.

The reality, however, is there is not enough money in the pot to allow everyone to get the treatment they need, and rationing is here to stay.  Although most hospital staff are caring decent people, many can and do work beyond their level of competence, free from accountability, with their mistakes and identities hidden from the public.

Most rationing in our hospitals also goes on in secret.  The elderly are usually the targets, although anyone who can be labelled as an unproductive member of society is at risk.  As well as working to stop this discrimination, Patient Protect aims to make patients aware of what is happening.  After all, secret rationing can only survive if it is kept secret.

Although the initial focus of this site was on NHS Hospitals, it is now clear that the problems we see are common to all areas of the health care system, both NHS and Private.  For more details of the state of the private sector, check the article "Private Hospitals can damage your health".  At present it seems that hospitalisation is safest as a private patient in an NHS hospital.

How rationing actually works.

1)Why the young, the elderly and the disabled are targeted for rationing.

The first thing to understand is that the new "NHS Trust Hospital" is really nothing more than a commercial business, run by business managers whose chief responsibility is to work within the budget set by the government.

The managers know that there is not enough money to allow all the patients to get the treatment they need (and which they were promised under the Patients' Charter) but they also know that to fail in their duty to provide proper treatment can lead to huge awards of damages in the courts.

The solution to this problem is to exploit the method the courts use to decide what the level of damages should be.  If the hospital negligently kills a 30 year old family breadwinner, they can end up compensating the family for the loss of future earnings - this can be millions of pounds.  Similarly, killing a mum with three young kids can lead to big payments for hiring cook, nanny, housekeeper plus compensation for any income she may have had.

Negligently killing a young child, an elderly person or someone disabled, however, is virtually free of these risks, for the simple reason that there is hardly ever any dependency requiring compensation.  Of course, families can and do complain bitterly, but 'toughing out' a complaint is cheap, as is the eventual issuing of an apology.

Government, of course, knows what is going on, but chooses to do nothing. Please readWatch out, you old chickens! for why.

2)   How rationing works at the level of the ward.

Compared with wards for younger adult patients, wards for the elderly are affected in three ways by rationing:

i)   reduction in quality and quantity of staff

ii)  reduction in quality and quantity of equipment

iii) tighter controls on what treatments can actually be carried out, regardless of how necessary they are.

A phenomenon known as "supply driven demand" then operates as staff learn not to ask for things they know they will not get.  Why do staff, whose primary duty is to put the interests of the patient first, accept these restrictions?

First, many of the staff who find these restrictions intolerable either avoid working on the wards for the elderly or quit altogether.

Second, of the staff who remain, some do care , but feel powerless to do anything.  All nurses know that if they complain, or stand up for the patients, they are going to face hardship and sooner or later get fired; all nurses know the story of nurse Pink.  Doctors also know that 'troublemakers' and 'whistleblowers' do not get good references or promotions and may, like Dr Bolsin have to leave the country to find work.  A recent survey in The British Medical Journal found that a quarter of staff in an (unnamed) NHS Trust reported that they had been subjected to bullying in the previous year.

Third, some staff simply do not appear to care. Staff guilty of awful cruelty and neglect can avoid a guilty conscience by using 'techniques of neutralisation'. Examples of these techniques in use include:

"The funding cuts aren't my fault" (denial of responsibility)

"She was going to die anyway" (denial of victim)

"The resources are better used on someone else" (appeal to higher loyalty)

Fourth, some staff have ended up callous and heartless.  Although they would not be tolerated on other wards, management allow them to remain on the elderly wards, presumably because they can be relied on never to stand up for the elderly patients.

3)  How rationing works at the level of the patient.

It can be summed up as 'Lambs to the Slaughter'.  Most patients and relatives will not realise (and will certainly not be told) that they are not getting a pressure relief mattress, even after they have developed bed sores; they naturally believe that the 'Nil by Mouth' sign over the bed is there for the patient's benefit (in some cases, no staff will admit to putting the sign there in the first place);  'Do not resuscitate' orders written in the notes frequently come to light only after the patient has died.  Even if the relatives or patients do realise what is happening, it is often too late to reverse the damage. Patients, their relatives and their friends usually lack the experience and assertiveness to get past a skilful gatekeeper.

Secret rationing of treatment is bad enough, but there is worse.  Although some patients may die promptly following withdrawal of treatment, others are stronger and threaten to linger on.  These 'bed-blockers' often receive a helping hand with, for example, overdoses of diamorphine or diuretics.  Diamorphine (heroin) is fast and effective, especially in someone unused to the drug and already weak. First it induces coma, followed by respiratory depression, and death.  For the hospital, this has the advantage of having the patient slip away quickly and quietly without any fuss.  Diuretics cause dehydration, and although the result is ultimately the same as with diamorphine the patient may survive, conscious, for up to a week even with the imposition of a 'Nil by mouth' regimen.  Relatives who do not know the signs of dehydration may be tricked into believing that the rapid deterioration is due simply to the underlying illness.