Monday, 26 November 2012

Liverpool Care Pathway – An Island Pathway

This is Jersey Evening Post -

End-of-life medical care ‘not euthanasia’

Thursday 8th November 2012, 3:59PM GMT.
Health Minister Anne Pryke
Health Minister Anne Pryke
A CONTROVERSIAL programme which allows doctors in some cases to withdraw food and water from dying patients is used in Jersey but is ‘not euthanasia’, the Health Minister has said.

Deputy Anne Pryke was responding to a question from Senator Sarah Ferguson about the Liverpool Care Pathway, a programme for delivering palliative care to people with a terminal illness. There has been criticism in the UK press recently about the programme, which recommends in some circumstances doctors withdraw treatment, food and water from sedated patients in their final days. Family members have complained that their relatives were denied rehydration in hospital and died in acute pain and discomfort with no knowledge of, or agreement to, being put on the pathway.
Senator Ferguson said that she had concerns that the programme might be used to ‘hasten death’ and this had been compounded by the fact that it was reported that UK hospitals were being paid to use the Liverpool Care Pathway.

There are some interesting responses posted here -
From the Communitarian; the Logician; the Prophet...

The problem is that as the population ages at the same time as the number of workers falls then it is a time bomb waiting to go off. Elderly care will take up more and more of the island’s GDP in the coming years that it risks collapsing the economy.
From an economic point of view what costs less? Keeping someone alive for years when they need intensive/extensive care or letting them die sooner? Resources can only be spread so far. What happens when they can’t be spread any further? Decisions will have to be made where to spend the money.
For example you have £1M, do you spend it on 100 workers to enable them to keep being economically active or on 4 or 5 elderly people who need costly care to be kept alive? I think I know the route the authorities would take.

  •  John
    That is frighteningly similar to something practiced under the nazi regime.
    It is interesting and chilling to see how the same basic concept can be dressed up here in respectable clothes in a hope to win a political point. The similarity with the german predecessor is striking.

  •  Mjolnir de Jersiaise
    So there you have it: forced euthanasia in a cold, heartless utilitarian society. Whose next? The mentally ill? The depressed? The unemployed? Jews? Beans?
    And maybe it takes too long to starve individuals in a hospital; how about articulated lorries with exhaust pipes plumbed into the back? There’s room for about fifty people at a time…

The ideas have been floated and have have been swept abroad, far and wide, to lap distant shores, every foreshore and backwater. And in Jersey they should know and take heed, for the Nazi jackboot stomped there for five long years.

These cold, clinical, logical Communitarian ideas create a culture of unfeeling care. And care that does not feel, that is numb and dumb and devoid of compassion, cool and calculating, is already programmed to step in and do the right thing, to impel the suicide and the runt into the abyss rather than haul them back from it. 

It is for their sake this is done and for the greater good. 'Human rights' must be respected; those who wish to die must be aided in this and those whose lives are not fit to live must be aided to end their lives. A Pathway. Much more polite and politic, yes, and sanitary, than an oven.

From the States Assembly 




1. What are the controls and procedures used for the Liverpool Care Pathway in
2. How long has this procedure been used in Jersey?
3. In how many cases has this procedure been used?
4. Have there been any complaints and, if so, how were these resolved?


1) The controls and procedures used for the Liverpool Care Pathway in Health and Social
Services are those recommended by the Marie Curie Palliative Care Institute in Liverpool.

 The approach is endorsed by 22 separate organisations which include several of the Royal
Colleges and National Bodies such as : The Royal College of Physicians, The Royal
College of General Practitioners, The Royal College of Nursing, The National Care Forum,

The British Geriatrics Society, Age UK and The National Council for End of Life Care.
The introduction of the Liverpool Care Pathway within Health and Social Services has
been managed through a range of measures to ensure the correct procedures are followed
and appropriate controls are in place to monitor its use, which include:

• A training programme for clinical staff, supported by resource packs containing
guidance information available in the clinical areas. The training covers 4 main areas
which are ( in bold)  communication and the need to discuss and engage with
relatives at all times, to support a shared agreement in care, to provide support to
relatives, to establish points of contact. To agree and understand advanced care
planning, taking into account patient wishes, preferred priorities of care, aiming to
support the patient to die in their place of choice.  Medication - to strengthen
knowledge and understanding in relation to the main medications used to manage
common symptoms such as pain, agitation, nausea and chest secretions and to ensure
medication is prescribed so it can be given when needed in order to minimise any
possible suffering to the patient. Spirituality, ensuring that the beliefs of the patient
are understood by all caring for them and appropriate plans in place. Continuous
review, this is an important part of the training to ensure staff understand the fluidity
and flexibility of the pathway. That care needs are regularly reviewed and
appropriate interventions made to ensure that the patient is comfortable and their
symptoms are managed.

• Clinical Guidelines - the Pathway is supported by number of clinical guidelines,
which provide clinicians with information to support their decision making, these are
available in the clinical areas. • In addition to this there is guidance to support the decision making process in diagnosing dying and the use of the Liverpool Care Pathway supporting care in the
last hours or days of life. These guidelines are part of the Liverpool Care Pathway package.

• Monitoring and Audit - In addition to the above the use of the pathway  is
monitored and audited.  

• Liverpool Care Pathway Facilitator  – through funding from Macmillan HSSD
have been able to employ a registered nurse to fulfil this role. She works as part of
the Palliative Care Team and has led on the introduction of the pathway.

The decision to start a patient on the pathway will be made by the multidisciplinary team
caring for the patient, in agreement with the patient’s family. The recording of this decision
is the responsibility of the most senior doctor available and endorsed by the Consultant
who is caring for the patient.

Initial and ongoing assessments of the patient will be done by doctors and nurses caring for
the patient (ie more than one professional).

The pathway is intended as a tool to ensure all care needs are considered and appropriately
met, regular reviews of the patient by more than one professional supports appropriate use
and if clinically appropriate, patients can/do come off the pathway.

2)  Health and Social Services have introduced the most current version of the Liverpool Care
Pathway during 2012.

3)  To date 23 patients have been cared for using the Liverpool Care Pathway within the
General Hospital

4)  There have been no complaints since its introduction

And this is the profit from writing letters –

So, what additional profits are our GPs making from CQUIN payments...?




1. How many rebates were claimed by GPs for the year 31st October 2011 until 31st October 2012 and at what cost?  

2. How much of the cost was associated to referral letters? 

3. What checks and measures were made to ensure only legally allowable claims were made? How frequently have these checks been made in the last 10 years and in what form?  Has evidence of other practices been looked for or found? If so, what action was taken? 

4. How many, if any, were found to be incorrect claims (e.g. requesting X-rays or “telephone 
consultations”, etc) during the period October 2011 to October 2012?. 

5. Are there any other doubtful claims for rebate payments being made? For example are two claims (one for the prescription and to administer it) being made to give one flu vaccine? If this has happened, what has been the cost to the Health Insurance Fund in total and per signature rebates? What action has been taken? 

6. What measures have been taken in relation to false claims and what monies have been 

7. If evidence is found that false claims have been made what action will be taken against 
such claimants? 


Information has been provided for the period 1 October 2011 to 30 September 2012.  Whereas most rebate claims from GPs are submitted and paid within a few weeks of the consultation, a time period of up to six months is allowed for these claims to be submitted.  The figures reported below represent rebates that have been processed up to the date of the data extract, and will be subject to change as additional claims are processed. 

The rate of medical benefit between 1 October 2011 and 26 June 2012 was £19.59.  Since 27 June 2012, the value of the benefit has been £20.28.  

Currently,  409,000 claims have been paid at a cost of £8.06 million for the year to 30 September 2012 

Of this total, the total costs associated with medical benefits provided for letters of referral was £0.99 million. 

Claims are  checked automatically using  embedded business rules within the Department’s IT system  before processing  and invalid claims are rejected, according to those business rules. These rules include automatically rejecting multiple claims for the same consultation and alerting the Department if a patient has more than one visit/claim within 24 hours from a single surgery. In the latter scenario, payment is not made unless the surgery can confirm that it is a genuine instance of 2 separate claims.   When claims are rejected, this information is provided to the GP, as each batch of claims is paid. 

In addition to these automatic checks which are applied to every claim submitted, the Department undertakes periodic random checks on claims by confirming details with the individual patient, by either letter or phone call. The Department also writes directly to surgeries, again on a random basis, to confirm details of claims.   Checks are also specifically undertaken in respect of patients with high numbers of consultations. 

A Medical Director has recently been appointed to lead the Primary Care Governance Unit and he has already undertaken a number of visits to local practices to ensure that best practice is being followed and has initially focussed upon practices  with high levels of consultation or referral letters 

Between 1 October 2011 and 30 September 2012 2,438 claims were disallowed. 

The claims submitted by GPs include information on the identity of each patient and the date and time of their consultation.  If a GP were to falsify claims, this might amount to fraud and could be referred to the Police for investigation accordingly.


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  3. Here's what the Muslim doctors feel about the LPC:

    "Muslim Doctors to meet amid fears of euthanasia on Liverpool Care Pathway."

    ** "it follows complaints from some Muslim medics that they were being placed under pressure to collude in the killings of NHS" patients***

    "Senior Muslim doctors have called a summit amid mounting concerns that thousands of elderly and terminally-ill patients are having their lives prematurely ended to free up hospital beds.

    They will meet next month to discuss fears that the Liverpool Care Pathway (LCP) is being used as a euthanasia pathway in the NHS, in hospices and in private and residential care homes for the elderly.

    Dr Jafer Qureshi, a consultant psychiatrist and a senior member of the Muslim Council of Britain, will host the meeting of about a dozen senior Islamic physicians in his home city of Birmingham.

    He said it follows complaints from some Muslim medics that they were being placed under pressure to collude in the killings of NHS patients.

    He said that many Muslim physicians objected to the sedation and withdrawal of artificial nutrition and hydration from seriously-ill patients under the LCP because it contradicts the Islamic ideal of death with dignity.

    “Doctors I have spoken to were concerned about pressure being brought to bear on them over the withdrawal of food and fluids,” said Dr Qureshi, a founder and executive member of the Muslim Doctors’ and Dentists’ Association and a co-convener of Medical Ethics Alliance.

    “They have managed to deal with the patients by saying ‘it is essential to keep them hydrated and moist’ … but (staff) have prevailed on Muslim doctors to say ‘let them go’.”

    Dr Qureshi added: “Muslim doctors are strongly of the view that for physicians to unnecessarily prolong life is not acceptable, but hastening death deliberately is not acceptable either, and if pumping somebody with morphine then dehydrating them is not that, then what is it?” "