Liverpool Care Pathway - The Importance Of Remaining Earnest

In keeping your friends close but your enemies closer, the situation may arise that you cease to recognise who is truly friend and who is truthfully foe. It is also to place yourself dangerously close to their circle of interest such that they beguile you into accepting their view at the expense of your own.

It is, therefore, important to retain integrity and to remain alert not to be swept along on the tide of events and, as a consequence, settle for a compromise of principle.

On the weekend, Sarah Julian interviewed Dr. Peter Saunders and Denise Charlesworth-Smith on her program on BBC Radio Nottingham. A transcription follows below.

Failing to learn the lesson of his political counterparts, Dr. Saunders performed the same gaffe as did Mr. Hunt recently, making little and light of the hurt and the harm families have suffered, diminishing the extent of the tragedy and, in doing so, piling insult upon grief.

Dr. Saunders, your prejudice has blinkered your vision. Like Priest and like Levite, you avert your gaze, not wishing to see what has befallen the innocent traveller upon the Pathway!

Dr. Peter Saunders:

"[It is] overall, a good thing that has been misused in a few cases and we want to see those few cases really stamped out so, it's a bit like an airline trip - every mistake means that your next trip is safer."

This is one quote among several that are really quite 'unfortunate' to put it politely.

This is Andrew Bridgen at Westminster Halls -

Andrew Bridgen raises his concerns about theLiverpool care pathway

Speaking during a debate on the Liverpool Care Pathway, Andrew Bridgen raises his concerns that local anecdotal evidence suggests that there is little opportunity for patients to be taken off the care pathway if they improve.

Andrew Bridgen: I thank my hon. Friend for calling this very important debate. I, too, share some of his concerns about the consistency with which the Liverpool care pathway is implemented across the country. I made some inquiries in the hospitals that serve my constituents, but information seemed to be lacking on the implementation of the care pathway. I am particularly concerned that patients placed on the pathway may have no opportunity to be taken off it if they improve. There are no figures on the number of patients for whom care has been reintroduced after being placed on the pathway. One of the hospitals told me, anecdotally, that no one there could remember anyone being taken off the pathway. I find that worrying.

Dr. Saunders says that the Liverpool Care Pathway was

"rolled out through NICE and through a government white paper in the mid 2000s.."

The Government published its NHS National End of Life Care Program in 2008 and invited the NCPC to groom the British public into accepting the idea of dying as a positive life choice. Out of this was formed the Dying Matters Coalition. The NCPC has led the Coalition since 2009.

The Department of Health committed to investing 286 million pounds over the two years to 2011 to support implementation of its National End of Life Care Strategy.

The problem with the LCP is that it is a killing machine in anyone's hands. It demands that a condition of 'dying' is determined which already prejudices the direction of further treatment and actually directs outcome.

This is Soh Tze Min and Sheila Ng -

Reference 1: "The Solid Facts: Palliative Care" edited by Elizabeth Davies and Irene J. Higginson

The report highlights a myriad of challenges of mainstreaming palliative care: the fact that most common chronic diseases (unlike cancer) have uncertain prognoses, which makes assessment of the need for palliative care difficult.

"Without a doubt, end-of-life care is fraught with complexity and controversy. For example, there is continuing debate whether it devalues life by abandoning curative efforts too early, or is more respectful of life as it seeks to give the dying greater dignity and quality of life. While most respect individual choice and one's right to die with dignity, interpretations—whether individual, societal, cultural, religious or clinical—of what constitutes "quality of life" in one's dying years vary greatly. There is also a lingering perception that palliative care can result in substandard medical treatment, or is a way to end the burden of caregivers." 

Ethos Perspectives — May 2007 Soh Tze Min and Sheila Ng Social Policy)

Dr. Peter Saunders:

"the problem with something like the LCP is that if the payments [CQUINs] are linked to the number of people put on it and then the people who are supervising it are not properly trained and there's inadequate communication or it's used inappropriately on some patients who are not imminently dying within hours or days, then you get problems.You know, perhaps with Managers driving agendas and junior staff, a bit of laziness and so on, can be a difficult cocktail, and that's the sort of thing that we want to see stamped out of what is essentially a very good framework that's improved care."

This is much more than a 'problem'. People are dying. The 'problem' is much more widespread than these reported cases and those still coming to light. The right honourable Andrew Bridgen MP made this very clear at Westminster Halls. Although, this is much more than 'worrying'.

Everything that these medical professionals are saying supports a criminal case of corporate manslaughter to be brought. Dr. Saunders makes an 'unfortunate' analogy of an airline trip that goes wrong. In such cases, the aircraft are grounded until such time as a full investigation has been undertaken by the appointed independent professonal body whose integrity is beyond question!

Dr. Saunders, one more thing, on the Death Pathway, there won't be a 'next trip'!

This is  BBC Radio Nottingham  6 January. 
(Dr Peter Saunders, CMF / Denise) Listen from 2hrs 22 mins to 2hrs 30 mins




Transcription of Broadcast -

Sarah Julian

The Christian Medical Fellowship has joined in the debate on the controversial Liverpool Care Pathway calling on the government to consider nine main points as part of a review 
it announced at the end of November. Figures obtained by BBC Radio Nottingham in November show that over half those who died at The Queens Medical Centre were on the LCP at the time of their death. That figure for Kingsmill Hospital is a fifth.It's a controversial regime, you've probably heard about it, it's come under intense scrutiny lately and allows doctors to withdraw treatment in the last days of life. The chief Executive of the Christian Medical Fellowship and representative of the group Caring Not Killing is Dr. Peter Saunders on the line now. Good morning.

Dr. Peter Saunders

Good morning.

Sarah Julian

What is your position on the LCP?


Dr. Peter Saunders

Well, we think that the LCP is basically a good thing that has been misused in some cases
Just to understand the history of it...Just to understand the history of it - It all started up in Liverpool in the 1990s with the Royal Liverpool Hospital and Marie Curie getting together to set out a framework to help patients in the last  hours or days of life to get good treatment because a lot of patients, particularly in District Hospitals, were suffering from pain or nausea or anxiety or other symptoms that weren't being properly controlled and they wanted to get the very good care that's available in hospices much more widely available in hospitals, and so it was rolled out through NICE and through a government white paper in the mid 2000s. And now, as you say, about a third of patients countrywide die on this framework.

Sarah Julian

And there's been a lot of unease about it, lots of people unhappy about it, particularly with things like withdrawing food and fluids, and... and ... People feel uncomfortable with it and they're pseudo patients on it, their family and relatives...

Dr. Peter Saunders

There has been and there's been a lot of coverage in some of the national newspapers in particular. We think, on the one hand, there are tens of thousands of patients who have had much better care at the end of life because of it but there have also been cases where there has been very justified criticism and the main problems are that first of all that some people have been put on it who are not imminently dying within days or hours and that's entirely inappropriate and there's been some inadequate supervision so that junior staff who have not been adequately trained have been used to oversee it. Some relatives haven't been properly informed that their loved ones have been put on it, so there has been poor communication and there's also been a bit of controversy surrounding payments being given to hospital Trusts setting targets for the number of people to be put on it and we think this is quite inappropriate...

Sarah Julian

Well, that does sound...

Dr. Peter Saunders

And it should be all around training people better to manage it, so overall, a good thing that has been misused in a few cases and we want to see those few cases really stamped out so, it's a bit like an airline trip - every mistake means that your next trip is safer.

Sarah Julian

The financial incentives has been extremely controversial, as you said, you know allegations that hospitals are given these financial incentives to get people on a care plan for the end of life. That does actually happen then, does it?

Dr. Peter Saunders

Well under the new NHS there are financial incentives for just about everything. They're aimed at improving care right across the board, so your GP and hospital are encouraged to use the very best care that's available but the problem with something like the LCP is that if the payments are linked to the number of people put on it and then the people who are supervising it are not properly trained and there's inadequate communication or it's used inappropriately on some patients who are not imminently dying within hours or days, then you get problems.You know, perhaps with Managers driving agendas and junior staff, a bit of laziness and so on, can be a difficult cocktail, and that's the sort of thing that we want to see stamped out of what is essentially a very good framework that's improved care.

Sarah Julian

Mmm, well okay,  let's talk with Denise Charlesworth-Smith. She's taking part in this government review after her 82 year old father Philip was put on the Liverpool Care Pathway at Kingsmill Hospital, she says, without the family's permission and, she says, despite the fact that he was getting better. Denise, good morning.

Denise 

Good morning, Sarah.

Sarah Julian

Do you agree with what we heard there from Peter that' it's essentially a good thing, it's a good tool, but that it does get misused?

Denise

I have met with Peter through the round table and we have exchanged emails previously and I have heard what he said. In essence, when John Allershaw developed it - and I'm going to see him this week - I understand he and his team were.. I think the aim of it was to actually provide a better end of life for those who were in hospices and who were terminally ill. The sad thing about it is it has been rolled out into the NHS into other hospitals and there are staff who are not trained in it.I have found out through talking to different people that we do have the instances of junior doctors who do not even have their general medical Council numbers who are actually putting people onto LCP. Now, my concern is, whilst Peter is talking about having better training, at the moment, it's still happening in the hospitals and we're coming down to the fact that how many more innocent people are being put onto it because the staff in the hospitals don't really understand what they are doing? I mean, I found out recently that an F1 doctor who had not graduated, who didn't have his GMC Council number, actually was only six months out and put somebody on LCP who was in a different ward to their experience, so basically what they were an experienced psychiatric person, and they were in a different ward completely. How on earth does that work?

Sarah Julian

So, you've been involved in this review then, I mean, so clearly...

Denise

Yes, yes..

Sarah Julian

Clearly very worried about this. I mean you have actually been to see the Health Minister
 and spoken to him. How do you think this review's going to go and do you think it will work?


Denise

I spoke with him on Thursday. I had a meeting with him in Norridge and we had a long chat about it  and I do know that he is going to be appointing an independent chair person to take this review on board. He has said to me that he wants to go through this piecemeal and thoroughly to make sure that things do happen. My concern now is that there are other MPs jumping in on the bandwagon and that it might start to muddy the waters of something that he has already picked up and started to deal with because they're looking to, obviously, glory seek. Now, these people are, obviously, going to be speaking on Tuesday in the commons. What I was going to say was, if there are any MPs who are listening to this programme today, they really ought to be directing it back through Norman Lamb and the roundtable and the review and the work that's already begun otherwise we're going to end up with two lots of different people doing the same thing and what's going to happen then? Conflict.

Sarah Julian

Denise, thankyou. Thankyou very much. And I'm sure we'll here from you again, Denise Charlesworth-Smith. And also thankyou to Dr. Peter Saunders of the Christian Medical Fellowship. Thankyou.