Saturday, 30 March 2013

Liverpool Care Pathway - The PCRs

Netting the one percent...
"Well, here's to your 1%..."    - photo credit: 
The PCR (Palliative Care Register)

Most people, if asked, would express the wish to die at home. This hypothetical response to a hypothetical question is used as a reason to downsize expectation for those on the PCR.

The Communitarian concept of 'Fairness' is used also as a reason for inclusion. It all seems so reasonable. Thus is the scope of definition extended 
Each full-time GP will have an average of about 20 patient deaths per annum. Typically, 5 will be due to cancer, 5-7 organ failure (cardiac, renal, COPD), 6-7 through dementia, frailty and decline and 1-2 sudden deaths.[6] Palliative care will be appropriate to many more patients in their care (the average GP has 40 patients with cancer, for example) at any stage in the disease and treatment path from pre-diagnosis to bereavement or survivor support. 
Palliative care provision remains uneven in the UK. The 2004 House of Commons Health Committee's 'Inquiry into Palliative Care in England' found: 
  • Gross inequality of access to hospice and other specialist palliative care services by diagnosis (95% went to people with cancer).
  • National Institute for Health and Clinical Excellence (NICE) guidance on 'Supportive and Palliative Care for Adults with Cancer'[7] should be fully implemented and its underlying principles should be extended to develop palliative care for patients suffering other life-threatening conditions.      (Palliative Care)
A palliative care document (PALLIATIVE CARE DES 2012 - 13) says -
Level 1 activity
  • Encourage the identification of patients approaching the end of their lives who have, or are likely to have, complicated or complex needs
  • Encourage the formation of an Advanced / Anticipatory Care Plan (ACP), ideally with the involvement of the patient and carers
  • Encourage the transfer of useful clinical information to OOH services
Level 2 activity·   
o       Encourage reflection on expected deaths
o        Including patients dying with cancer, non-malignant disease and with/without ePCS
o        Also encourages reflection on patients with/without DNACPR, on/not on PC DES register, preferred place of care and use of end of life care pathway (LCP or equivalent)
·         Encourage the use of the Liverpool Care Pathway (LCP) in the management of the last few days of life

This is all airy-fairy. 'Have or likely to have'. With and without ePCS (electronic Palliative Care Summary'.

The Palliative Care DES (Directed Enhanced Service) provides financial reward for the GP practice -
Level 1 activity·        
·        Payment is per patient and is not capped.
·         Data will be extracted automatically by use of the ePCS
·         There is no longer payment for use of the LCP for the last few days of life
Level 2 activity·        
·        A standardised report must be completed detailing reflective practice.
·         This will involve malignant/non-malignant, use of ePCS, expected/unexpected death, preferred place of care, use of LCP amongst other aspects
The Communitarian concept of 'Fairness' steps in again -
·         It is also important that practices attempt to ensure that patients, particularly those with non-malignant disease, are not overlooked and therefore it may be useful to construct a second, less formal, register of patients who are possible candidates for future inclusion in the PCR
A document from NHS Lothian in Scotland (PALLIATIVE CARE A Brief Intervention) supplies a flow chart -

The document advises the GP to register the patient on the ePCS and obtain consent after -
The Palliative Care DES
• Decide who should be on it (see ACP / ePCS)
• Add data via ePCS template
• Then
   –  Obtain consent
   –  Add palliative care review date
   –  Add to Palliative Care register

The Palliative Care DES
• Patient cohort – patients on palliative care register
• 2011 – 12
   • ACP & transfer to OOH medical service within 2 weeks
   • Payment based on percentage achieved
   • Capped c6.5/1000 patients
   • Payment (token!) for using LCP
• 2012 – 13
   • ACP & transfer to OOH medical service within 2 weeks
   • Payment per patient
   • No cap
   • No LCP payment
   • Level 2 payment for SEA

[glossary of terms: • Anticipatory Care Planning (ACP). – Including 'My Thinking Ahead & Making Plans'. • electronic Palliative Care Summary (ePCS). • Palliative Care DES (Directed Enhanced Service). • Significant Event Analysis (SEA)]

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