Liverpool Care Pathway – The Economics Of A Communitarian Health Service

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 Patient Protect -

How rationing actually works. 

Last updated 27 August 2009

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.

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 staffii)  reduction in quality and quantity of equipmentiii) 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.

How to protect yourselves from rationing.  

1)   Prevention 

Staff are likely to be more diligent and much less willing to participate in rationing and abuse if they know they can be identified later.  Always keep a notebook and pen handy, and keep them visible.Ask at the nurses' desk which nurses are responsible for hydration, nutrition and pain control.  Write these names down as you get them.  These names should be clearly stated in the Nursing Care Plan.Write down the name of the person you are talking to.Ask for the name of the consultant responsible for the patient, and also ask for the name of the doctor who will be responsible for the day to day management of the case.If you ask all these reasonable questions in a friendly manner, you can expect straightforward civil answers.  If you feel you are getting fobbed off with excuses like 'it's confidential' or 'too busy' or 'you don't need to know' then do not get upset.  Simply go to (or phone) the Customer Services Officer and ask them to find out for you (don't forget to ask for their name).  Explain that it is important that you know who is responsible for what in order that communication can be improved and problems can be avoided. If this does not work then send written complaints (see next section).  

2)   How to stop existing problems. The first step is to recognise that rationing and neglect are taking place.  Dehydration, bed sores and a general lack of attention from qualified staff (e.g. soiled bedding, call button out of reach, regular observations not being done) are all reasons to suspect neglect.  Are the staff reluctant to show you the patient's records and discuss the drugs being used?  Is Diamorphine PRN on the prescription chart?  Is a DNR order in the notes without your knowledge? Are you told that the Consultant/Doctor/Surgeon is too busy to see you?If you feel that the patient is deteriorating rapidly and their treatment seems to be the cause, rather than the cure, then step two is to complain effectively.  Rationing and neglect are top-down processes, so *  Complain by fax/email to the Chief Executive of the Health Authority responsible for the hospital (phone the local Community Health Council for his name, fax and phone numbers) and*  Copy this by fax/email to the Chief Executive of the hospital and Consultant responsible for your relative's care.*  Immediately follow up with a call to their secretaries and confirm receipt of the fax.  Stress to them that you will take things further if nothing is done.  Ask for their name, write it down together with the time of the conversation.  Send faxed copies to the other organisations (see below).  Keep fax receipts.*  Keep records of all significant events - keep a diary with names of staff, what they do/do not do, etc, record conversations (use recording walkman, dictaphone, mp3 recorder, mobile phone etc), photograph evidence of neglect.*  If the situation does not improve rapidly, demand to see the Consultant and demand an immediate transfer for your relative.

The conspirators are stepping out of the closet.

Those once 'made comfortable' are now, in the words of Dr. Sophie Harrison writing in the Financial Times, “LCP-ed”.

In recognition of the necessity to ration healthcare, the Communitarian Health Service is, through a process of 'floating ideas' over a period of years, becoming reality.