Wednesday, 27 March 2013

Liverpool Care Pathway - What We Know Now

The Guardian Healthcare Professionals Network 
identifies an ageing population and pressures on public spending as targets for an EoLC refocus.

The author also refers to the Francis Report and NHS reform in this context. This falls in line with recent recommendations to keep the elderly out of 'dangerous hospitals'.

The focus in EoLC is necessarily going to be on economy of treatment and downsizing expectations.

In the article, authored by Dr. Phil McCarvill, Head of Policy at Marie Curie, a shift in care is recommended
"We are not calling for a mass clearance of hospital wards, but rather for a well-planned, system-wide programme to shift resources and support available in care homes, hospices and people's own homes." 
"Tens of thousands of vulnerable and elderly patients should be treated in the community, the doctors say, where they will be more safe than in hospital. 
The appeal follows the public inquiry into hundreds of avoidable deaths at Stafford Hospital." [Mail Online]
The author urges  that 'we must also increase the number of people with Advance Care Plans'.
"What we have learned over the past twelve months provides us with the evidence base required for such a shift."
This is the National End of Life Care Programme Intelligence Network and What do we know now that we didn’t know a year ago? -

9. What we know about costs of care

9.1 If all people who die in hospital stayed only a maximum of eight days, then the total estimated cost to commissioners would be lower by approximately £357m pa.
(Source: Ian Blunt Analysis of Hospital Cost data – Nuffield Trust unpublished)

9.2 The estimated total cost of acute admissions ending in death in 2010-11 was over £520m.

9.3 In England a 10% reduction in the number of hospital admissions ending in death could potentially result in a saving of £52m.
(Source: CMG42 Guide for commissioners on end of life care for adults. NICE, 2011) Quality Innovation Productivity and Prevention (QIPP) data:

9.4 The majority of people admitted as emergencies in the last of year of life have only one or two such admissions. However in the five year period between 2004 and 2008 an annual average of 83,760 people had three or more emergency hospital admissions in the last year of life, which is almost a quarter of all people with at least one such admission.

9.5 The price of an inpatient admission in the last year of life that ends in death is estimated to range from £2,352 - £3,779, with NICE estimating the cost to be £2506.

9.6 The cost of an inpatient bed day in the episode of care that ends in death is estimated to range from £200 - £425.

9.7 Whilst there is considerable difficulty in measuring the costs of community-based end of life care, it is estimated to range from £1,415 - £2,800 per person, per episode at the end of life.

9.8 Taking a midpoint of the estimated inpatient (£3,065.50) and community-based (£2,107.50) end of life care costs, there is an estimated potential net saving of £958 per person who dies in the community.

9.9 A 10% reduction in bed days for the cohort with a length of stay of more than eight bed days ending in death could yield savings of around £57m in hospital costs at £200 per bed day. However, any reduction in bed days must be based on clinical need, quality of care and individuals’ preferences. Additional costs in the community would be anticipated.
(Sources: QIPP Indicator for End of Life Care. Proposal of a new indicator, NEoLCIN, unpublished
QIPP End of Life Care. Hospital admissions in the last year of life, NEoLCIN, unpublished
QIPP Reviewing end of life care costing information, NEoLCP, Apr 2012)

This list clearly demonstrates and supports the financial advantages involved in switching the emphasis. The pensions ‘black hole’ is non-sustainable; ipso facto, neither are pensioners. 

The argument is a clear and favourable one, to protect the elderly, the frail and fragile, the vulnerable from 'dangerous hospitals'. This will ease and facilitate the policy to lower expectations, to shift care from the curative toward the palliative. Better to ration scarce medical resources by not providing them.

This is a consequence of adopting the Communitarianism promoted by Ezekiel "Zeke" Emanuel and Don Berwick. The latter has been appointed Guru to straighten out the NHS.

The Guardian author sums up:

For commissioners, the challenge is clear – they must shift resources from acute hospitals to community-based care, including hospices, care homes and people's own homes. What we have learned over the past twelve months provides us with the evidence base required for such a shift. 
The first step will be to ensure that community based end of life care is a top-level local priority. The second, that local commissioning encourages co-operation and co-ordination, so that people get the services they want and need. 
The ongoing pressures set out above underscore why we need such a major shift now. Rebalancing of care for dying people will not only help ensure the long-term sustainability of the health and social care system, but also give people more of what they want. This can only be good news for both individuals and the system. 
Dr Phil McCarvill is head of policy at Marie Curie Cancer Care.
Rebalancing care for 'dying people’…? 

What if our elderly require curative hospital care? Should they still be kept out of hospital because hospitals are ‘dangerous’? Isn’t it time to make our hospitals safe...?

What do we know now that we didn’t know a year ago? here confirms the 2013 CQUIN –

16. What we know about other research relating to end of life care... 

16.8 Impaired cognitive function is an independent predictor of mortality.
(Source: Sampson EL., et al., Survival of community-dwelling older people: the effect of cognitive impairment and social engagement. J Am Geriatr Soc. 2009 Jun;57(6):985-91)

It is the financial argument which is paramount in this discourse, and 'long-term sustainability'. It is the rationing of scarce resources. The author argues that 'this can only be good news for both individuals and the system.' That will not be the case for those connived to accept palliative in place of curative care.

reports -

  • 94% of relatives/carers were given a full explanation of the care plan (LCP); healthcare professionals were able to discuss this with 56% of people at the end of life

Another doctor once said, 
“It would not be impossible to prove with sufficient repetition and a psychological understanding of the people concerned that a square is in fact a circle. They are mere words, and words can be moulded until they clothe ideas and disguise.” 
 Joseph Goebbels

“The bigger the lie, the more people will believe it.” 
 Joseph Goebbels, Die Tagebücher. Geschichte & Vermarktung

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