Liverpool Care Pathway – Surprise, Surprise?

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WEDNESDAY, 13 JULY 2011

LIVERPOOL CARE PATHWAY - A GRAVE AND PERILOUS PATHWAY

The Department of Health (DOH) uses a Commissioning for Quality and Innovation (CQUIN) payment framework which enables commissioners to reward excellence by linking a proportion of providers’ income to the achievement of local quality improvement goals:

"It makes a small proportion of provider income (0.5% of contract value in 2009/10) conditional on achievement of locally agreed goals around quality improvement and innovation. It is intended that goals should be stretching but realistic."

CQUIN has set targets for 2011/2012 with regard to the End of Life program.

The forward plan is to increase the number of patients identified to be on the end of life care pathway and from a baseline of 0% to 20%; it is further planned to have 30% of all patients who die in hospital dying on the Liverpool Care Pathway.

To ensure they receive their provider income in fulll, Trusts have to comply with or exceed these goals. Some, like Royal Brompton, have upped the plan expectations:

1) 95% of patients identified as end of life (last 48 hours of life for expected deaths) are offered an EOL care planning discussion
2) 80% of patients offered a discussion should have an advanced care plan
3) 98% of patients who have an advanced care plan should have a record of the decision to resuscitate stated clearly in the notes
4) 50% of patients who die in hospital (expected deaths) should die on a Liverpool care pathway 

It is the DOH which is the driving force behind rolling out  LCP across the NHS!

From 'cradle to grave' was the promise. Cradle to grave has become a bit of a stretch with the pressure of the financial constraints involved. (It's that bit in-between that's the problem!)

Putting pressure on clinicians to identify patients as 'dying' to place them on LCPsimply to achieve these DOH targets is fraught with peril! Clinicians will be hounded, against their better judgement, by cash-strapped Trust's business and finance managers to meet targets in order to sustain funding.

A 'high quality' life cannot be guaranteed but, by golly, they're going to make darned sure we all get a 'high quality' death!

Mr Lamb cannot have been unaware of this, so why is everyone expressing such surprise...?

This today from The Telegraph -

Liverpool Care Pathway: minister orders report into cash rewards

A Minister has ordered an internal investigation into the use of payments to hospitals for getting terminally ill patients onto a controversial care “pathway” to death.

By John Bingham, Social Affairs Editor

6:30AM GMT 05 Nov 2012

Details released under the Freedom of Information Act suggest that three quarters of trusts use the technique, which involves reducing invasive treatment – potentially including food and fluids – given to people in the final days and hours of their lives.

The returns suggest that between £20 million and £30 million has been paid out in the last two to three years to trusts which have hit targets linked to the use of the LCP.

Mr Lamb said that the payments, which are made by local NHS bodies rather than the Government, could well be ensuring people in terrible pain have a better and more dignified death.

But he said he wanted to be satisfied that they were being used appropriately.

The pathway, developed in Liverpool, was designed to enable dying patients a more comfortable and less painful death.

But a string of examples have come to light in which relatives claimed that their loved one was put on the pathway either without discussion with the family or where they might not have been imminently dying.

A series of changes to the NHS Constitution to be announced by the Government today will include giving patients and relatives an explicit right to be consulted at every stage of end-of-life treatment, where possible.

The proposals would also open the way for hospitals which depart from guidelines to face legal challenges on behalf of patients.

Many of the targets for which trust have received payouts relate to how much involvement loved-ones of people on the pathway are given or how closely it is monitored.

But in other cases they have been set explicit goals to get a set number of terminally ill people on the pathway.

Mr Lamb said: “I have asked for a report internally on the various ways in which these payments are being made.

“I have made clear that payments should only be made where it is demonstrably [promoting] better care.

“You could say that given that the care pathway involves patient discussion and engagement with lived ones, done properly, getting more people on to an approach which guides the clinicians through proper judgment, if that ends up with people having a better experience than a more haphazard approach then that’s a good thing.

“But I want to know that payments are only being made where objectively and rationally we can conclude that it is resulting in a better outcome.

Under the proposals being outlined today, a section of the NHS constitution which says that patients have a right to a general say in their care will be toughened up to make clear they should be “involved fully” in “all discussions and decisions” about their care, adding: “including in your end of life care”.

It adds that people should be given special support to help them take it in makes clear: “Where appropriate this right includes your family and carers.”

Mr Lamb said shortcomings could potentially be challenged in the courts under new powers for the new Clinical Commissioning Groups.

“We have got to move away from an old model of the past of paternalistic care where the doctor knew best,” he said.

FOOTNOTE:

A new national CQUIN goal has been introduced for use in 2012-13.

Dementia Goal

An estimated 25% of acute beds are occupied by people with dementia. Their length of stay is longer than other people and they are often subject to delays on leaving hospital.

This particular goal is to help identify patients with dementia and other causes of cognitive impairment, alongside their other medical conditions and to prompt appropriate referral and follow up after they leave hospital.

There are more bed-blockers to shift. And where will this lead...?

The Mail continues to draw attention to the CQUIN payments system in the hospital setting but, as has been reported in these pages, this now extends into District Nursing and General Practice. CQUIN is, no doubt, also involved in the spread of the GP death lists and the use of LCP, for instance, in St. Mungo's and elsewhere.