Sunday, 25 November 2012

Liverpool Care Pathway – Corruption, Corruption, Corruption

It is no news that NHS Trusts are struggling financially. Gordon Brown's Private Funding Initiatives are a vast black hole into which many continue to free-fall.

The CQUIN scandal has encouraged corrupt practices such as 're-coding' patients to meet targets and to retain and obtain funding and has ensured the smooth rolling out of projects such as the LCP protocol.

The imposition of a centrally planned program will be more readily rolled out with unthinking approval when the financial heartstrings are plucked. It's a fast-track method of getting everyone on board singing unquestioningly from the same hymn sheet!

Earlier this year, the Telegraph & Argus reported -

Bradford NHS Trust on course for £4.5m surplus

Hospital chiefs in Bradford intend to take advantage of the Trust’s “strong” financial position to carry out a raft of improvements to patient care.
Bradford Teaching Hospitals NHS Foundation Trust, which runs Bradford Royal Infirmary and St Luke’s Hospital, is on course to achieve a £4.5 million surplus during the 2011/12 financial year – £1.2 million ahead of plan.
The surplus means the Trust will now seek approval, subject to business cases, for major capital developments during 2012/13, including a second new ward block and accessible entrance, a neo-natal intensive care unit, an adult high dependency unit, a cardiac catheter laboratory and centralised decontamination.
Other developments already agreed include the introduction of electronic medical records, electronic rostering and electronic prescribing and a new midwifery-led unit at BRI.
The Trust’s expenditure on capital projects in 2011/12 to date is £5.386 million.
The Trust’s financial performance has also secured it a financial risk rating of three from foundation trust regulator Monitor, meaning the watchdog believes it is unlikely the foundation trust will breach its terms of authorisation.
Matthew Horner, acting director of finance, said delivering a surplus in excess of the plan for 2011/12 provided a strong foundation for what he conceded will be a financially challenging year in 2012/ 13.
“We will deliver the financial plan this year,” he said. “It gives us a real opportunity to invest in patient care and the fabric of the organisation next year.”
Mr Horner said the Trust had also signed off the contract with its commissioners for the health services it will provide during 2012/13 .
“This provides a very good base for us to move forward, but we need to recognise challenges ahead,” he said.
In order to do so, the Trust is looking at the configuration of its beds and carrying out a review of acute admissions and readmissions.
Chairman of the Trust, David Richardson, said: “It is a very strong position that we find ourselves in.”

The Telegraph reported on the Audit Commission report in September –

NHS under pressure with more trusts in the red

Number of NHS trusts in financial difficulty has more than doubled in a year, an Audit Commission report warns.

The NHS ended 2011-12 with a £1.6bn surplus. But the differences between solvent trusts and struggling ones is growing, warns the Audit Commission.
The NHS ended 2011-12 with a £1.6bn surplus. But the differences between solvent trusts and struggling ones is growing, warns the Audit Commission. 

12:01AM BST 20 Sep 2012

Hospitals on the outskirts of London and across the south east are struggling to balance their books, according to the report, while those in the centre of the capital, the Midlands and northern England are tending to fare much better.
Across England, the Audit Commission found 31 ended the 2011-12 financial year with a deficit. That compares with just 13 at the end of the previous year.
The NHS Financial Year 2011-12 report, published today, notes that most trusts reported "an improved financial position”, with the NHS overall recording an unspent “surplus” of £1.6 billion, up on £1.5 billion the previous year.
“However, there is a growing difference between those organisations that are struggling financially and those that are not,” it goes on.
It warns of “stark geographical differences” such as those “between the relatively financially comfortable inner London NHS bodies and financially harder pressed outer London bodies”.

The Telegraph reports that,
 "the centre of the capital, the Midlands and northern England are tending to fare much better."

That fits in well with the Bradford Trust surplus. Plainly, what is happening is that those successfully massaging the figures through 're-coding' and meeting targets thereby are faring much better than are their counterparts.

Bradford defended their LCP policy recently as reported in these pages –

7:00am Saturday 3rd November 2012 in News

Bradford health chiefs defend end of life care method

Health chiefs in the Bradford district have defended the use of a controversial end-of-life care pathway for terminally ill patients in the face of negative press nationally.
Questions have been raised about end of life care (Picture posed by models)Eighty-five per cent of trusts nationally, including Bradford Teaching Hospitals NHS Foundation Trust, Airedale NHS Foundation Trust and Bradford District Care Trust, have adopted the Liverpool Care Pathway (LCP) which can involve withholding food, drink and treatment from terminally-ill patients

Almost two-thirds of trusts that have used the LCP have received financial incentives totalling millions of pounds, according to figures obtained by a national newspaper, including Bradford Teaching Hospitals NHS Foundation Trust which qualified for £490,000 over two years after doubling the number dying on the pathway to 51 per cent.

Payments are made to hospital trusts under a system called Commissioning for Quality and Innovation (CQUIN), where the NHS commissioners “reward excellence” by paying trusts to meet care targets.
A spokesman for NHS Airedale, Bradford and Leeds said: “In Bradford and Airedale, appropriate CQUIN payments were made to local NHS trusts to promote good, holistic care for patients at the end of their life.
Also reported in these pages –

MailOnline - news, sport, celebrity, science and health stories

The hospitals given a cash bonus if FEWER patients die 

  • UK trial led to 900 lives being saved over 18 months
  • Fewer deaths from hip replacements and conditions such as pneumonia 

A controversial scheme to give hospitals a bonus if fewer patients die has led to nearly 900 lives being saved over 18 months.

Twenty four NHS hospitals in the north west took part in the Advancing Quality programme where they are given cash incentives to cut mortality rates for conditions like heart attacks.

A total of £4.8 million over 18 months was available to share between those hospitals who showed the most improvement in their death rates.

NHS local reported -

High mortality rates can be "re-coded" by describing patients' conditions as terminal, Inquiry told.

Advancing Quality Alliance aims to "give patients a better experience of the NHS by making sure the highest standards of care are delivered in every hospital in the North West of England".

AQuA is already instigating and implementing this Communitarian Pathway throughout the North-west. Whilst advancing best care practices for best outcomes, a Rapid Discharge Program has been set in place -

Aqual NHS

  • The University Hospital of North Staffordshire has introduced a palliative and end of life rapid discharge pathway for those in, or approaching, the terminal phase of their illness
  • The discharge is arranged at the earliest opportunity and usually takes place within days or hours
  • It is already having a significant impact with around 45 patients a quarter discharged in this way.
Early identification and appropriate actions and discussions by medical teams are key to triggering the pathway and the hospital palliative care consultant has worked with medical staff at all levels to promote good practice in this area. Work continues to embed the pathway process into clinical practice across the trust.

Those selected for rapid discharge are effectively being shipped off to die. This all fits in well with the 'End of Life care Registers' - the Death Lists being drawn up by GPs of patients being diagnosed as 'dying' and being in their last year of life.

Professor Mark Glaser brands the LCP as ''the most corrupt practice in British medicine" -

MailOnline - news, sport, celebrity, science and health stories

Cancer expert who treated Mo Mowlam brands Liverpool Care Pathway 'the most corrupt practice in British medicine'

  • I wouldn't be treated in a hospital here, says Professor Mark Glaser
  • Senior oncologist accuses NHS managers to use the Liverpool Care Pathway in order to clear beds and reach their targets

A senior cancer specialist today condemned the controversial Liverpool Care Pathway as a corrupt and scandalous system used to free hospital beds of the old and sick.

Professor Mark Glaser said the Pathway – in use across the NHS as a way to ease the suffering of the dying – is employed by Health Service managers to clear bed space and to achieve targets that bring more money to their hospitals.
The professor, who treated former Labour Cabinet minister Mo Mowlam during her last illness, said practices in British hospitals are ‘morally bad medicine’ and that he would personally ‘never be treated in a hospital in England’.

Accusing: Oncologist Professor Mark Glaser says NHS managers use the Care Pathway to clear bed space and to achieve targets
Accusing: Oncologist Professor Mark Glaser says NHS managers use the Care 
Pathway to clear bed space and to achieve targets

I would go to America because I don’t trust anybody,’ he said.

He added that he has removed ‘dozens’ of his own patients from the Liverpool Care Pathway.

The intervention by Professor Glaser, consultant oncologist at Imperial College Healthcare NHS Trust, comes at a time of growing concern over the Liverpool Care Pathway.
    A centrepiece of the NHS programme for ‘end-of-life care’, it involves removing life-saving treatment from patients considered to be dying. Commonly, patients are heavily sedated and tubes providing nutrition and fluid are removed. Typically a patient dies 29 hours after being put on the Pathway.

    But families have complained that loved ones have been put on the Pathway when they were not dying and senior medical figures have said it is impossible to predict when a patient will die.

    Leading doctors opposed to the Pathway have said it hastens death and that putting a patient on it is a ‘self-fulfilling prophecy’.

    Corruption that is instigated and rolled out by central planning - even though government ministers may deny all knowledge of it - is absolute corruption. And absolute corruption corrupts absolutely!

    Here is the Communitarian Complete Lives System treatment priority curve:

    Govind Persad BS, Alan Wertheimer PhD and Ezekiel J Emanuel MD published this in The Lancet ([PDF] Principles for allocation of scarce medical interventions) in 2009.

    Basically, it's all about whose life is and is not worth saving. This redefines the physician’s duty. The duty is no longer to the patient but to what is considered the greater good. Hence, the Communitarian definition of health care.

    We have seen even the likes of Dr. Christian Jessen tweeting thus -

    This is dangerous stuff. Who decides what is the greater good...? 

    Why, the Great and the Good, of course! And who are they...? 

    The Advancing Quality Alliance (AQuA) page actually sports a link to the New England Journal of Medicine –


    Reduced Mortality with Hospital Pay for Performance in England

    Matt Sutton, Ph.D., Silviya Nikolova, Ph.D., Ruth Boaden, Ph.D., Helen Lester, M.D., Ruth McDonald, Ph.D., and Martin Roland, D.M.
    N Engl J Med 2012; 367:1821-1828November 8, 2012DOI: 10.1056/NEJMsa1114951


    Pay-for-performance programs are being adopted internationally despite little evidence that they improve patient outcomes. In 2008, a program called Advancing Quality, based on the Hospital Quality Incentive Demonstration in the United States, was introduced in all National Health Service (NHS) hospitals in the northwest region of England (population, 6.8 million).
    A wide variety of pay-for-performance programs have been developed for health care providers, and such programs are being increasingly adopted internationally with the aim of improving the quality of care.1 Medicare is scheduled to introduce pay for performance in hospitals across the United States in 2013 under its Value-Based Purchasing Program.2 Increased adoption of pay for performance is occurring despite a scant evidence base. According to a review3 published in 2009, only three hospital pay-for-performance programs had been evaluated, and good evidence was available for only one, the Hospital Quality Incentive Demonstration (HQID) adopted by the Centers for Medicare and Medicaid Services in 2003 and supported by Premier. These evaluations4-6 and later articles7-9 show at best modest and short-term effects on hospital processes of care. Evidence of an effect on patient outcomes is even weaker: the HQID has been shown to have no effect on patient mortality,10,11 and a 2011 Cochrane review found no evidence that financial incentives improve patient outcomes.12
    The links are plain and simple. Just join up the dots...

    Mr. Lamb, at your Round Table fireside chat tomorrow, let's have some straight talking and some honest answers, please.

    1 comment:

    1. I can see what you're saying - will have another look at this after lunch.

      One point that needs to be made, I believe, is that Cicely Saunders herself commented on the high cost of good quality hospice care.

      St Christopher's Hospice say they spend around £14 million a year on hospice care for around 2,000 patients.

      So, despite much unpaid support from volunteers, St Christopher's spend around £7000 per patient.

      That's slightly less than is spent in the US an by many other countries - see the table of international health care spending I posted a few days ago.

      However, its around half the amount of funding that our governments allow the NHS.

      The NHS in general, and care for those who are dying, in particular is, I believe, badly underfunded.