Saturday, 2 March 2013

Liverpool Care Pathway - When The New Is Not The News

All a sudden, there is a flurry of comment in the news. It is a matter of exceeding difficulty to sort the wheat from the chaff and what is new from what is just... 'news'.

Following a debate called by the Honourable Gentleman in Westminster Hall on 8th January, Glyn Davies writes in The House Magazine of 28th February and warns -
Criticism has focused on a lack of communication, with claims that doctors, nurses and carers have failed to inform the dying or their families that they are being cared for via the pathway. 
This is unacceptable.
Glyn Davies writes in The House Magazine 

This report on the 1st March by Stephen Adams in The Telegraph takes issue -

Liverpool Care Pathway: fifth of doctors quesy about always telling relatives

A fifth of doctors are ambivalent or even hostile to always telling relatives that they are putting a patient on the Liverpool Care Pathway, according to a survey.

Last November Norman Lamb, the care minister, said it was “simply unacceptable” that patients were being put on the controversial pathway “without a proper explanation or their families being involved”.
But an survey of some 563 doctors involved in end-of-life, carried out by the British Medical Journal and Channel 4, has revealed a substantial minority disagree with that view.

That's one in the eye for both Right Honourable Gentlemen!

It must be said, also, that those 20% of doctors who want to keep everyone in the dark and out of the loop really do have the law on their side to do so in those circumstances where they are variously covered by the Mental Capacity Act and the Data Protection Act. Mr. Lamb is going to have to accept that any proposed changes to the NHS Constitution have no standing against laws enacted by Parliament. Other amendments are in order.

The BMA published this on 28th February -

BMA Q and A: Putting patients first

BMA medical ethics committee chair Tony Calland answers your questions

Does the BMA medical ethics committee support the Liverpool Care Pathway?

Yes. The pathway was designed to guide doctors and nurses through best practice in palliative care for patients recognised as close to the end of life. It clearly requires good and regular communication with patients if possible and with relatives, as well as regular patient review, which should lead to titration of drug dosage to the patient’s clinical condition.
Through ignorance or misuse, the pathway’s value has been questioned, and this threatens to create confusion and uncertainty, and once again leave patients with suboptimal palliative care.
It is important that the forthcoming review, ordered by the government, looks at the training given to clinicians so doctors and nurses are fully aware of the criteria required before patients are included on the pathway, and of the review and communication requirements once a patient is considered to be near the end of life.
The chair of the BMA's Medical (Ethics) Committee thus confirms he remains at loggerheads with the chair of the BMA's ethical conscience, the Medical Ethics Alliance... 

The flawed concept of its design apart, what the LCP was allegedly designed to be bares no resemblance to what the LCP is in practice and there were six signatories to a published letter in support of Professor Pullcino's published comments on the LCP. These were -

Professor Peter Millard 
Dr Anthony Cole - Chairman, Medical Ethics Alliance 
Dr Rosalind Bearcroft 
Dr Gillian Craig 
Dr David Hill 
Dr Mary Knowles - Chairman, First Do No Harm 

[The Medical Ethics Committee surrendered its moral authority when a central pillar of its very standing was torn down ‘in one afternoon’. See this press release by Dr. Cole - "BMA abandons a major principle of medical ethics". And doctors may now, with a frightening banality (used in the sense of Arendt) openly tweet and twitter about the net upon what they consider is the absurdity of an oath that has formed the ethical basis of their profession for 2000 years!]

Well, that's the new. The rest was just... just... 'news'.

The Telegraph report previously mentioned says -
The survey, to which doctors responded anonymously, found strong support for the pathway.
The Pulse headlines -
90% of specialists would put themselves on Liverpool Care Pathway
NHS Choices reports -
90% of doctors 'support Liverpool Care Pathway'
The BMJ headlines -
Nine out of 10 palliative care experts would choose Liverpool care pathway for themselves
BMJ feature asks -
The Liverpool care pathway: what do specialists think?

This last article, it must be said, provides a marvellous array of graphs to give, well... graphical illustration of the predictably boring results which agree with what is reported elsewhere. I must say it does make it look very professional, though.

So, what is everyone saying? The LCP and other integrated pathways have been rolled out across the NHS and pretty much everywhere else, as reported in these pages. It would be surprising - given the high pressure sales pitch by the DoH EoLCP/NCPC and the indoctrination programmes that have been rolled out - if those using the LCP and who have undergone the programming and completed those six steps to success didn't support the LCP and want it for themselves when the doctors say it is time for them to die. Wouldn't it?

So, what's new? Well, it must look good to see the pro's backing their pathway I suppose...

Wait a minute, though. Let's look at that again, shall we? The article mentions that of 3021 UK hospital doctors emailed  for an anonymous online survey of their views on the Liverpool care pathway only 647 responded. That's only 21.4%. That being the case, that nine out of ten 90% doesn't look nearly so good...

Having looked at that impressive array of graphs shall we reproduce some from the Parliament website? These concern a matter of major concern to the Communitarian health rationers promoting the LCP and other integrated pathways and may explain the rationale of their intent.

Parliament UK
You are here: 

The ageing population

The UK’s ageing population has considerable consequences for public services
10 million people in the UK are over 65 years old.  The latest projections are for 5½ million more elderly people in 20 years time and the number will have nearly doubled to around 19 million by 2050.
Within this total, the number of very old people grows even faster.  There are currently three million people aged more than 80 years and this is projected to almost double by 2030 and reach eight million by 2050.  While one-in-six of the UK population is currently aged 65 and over, by 2050 one in-four will be.
The pensioner population is expected to rise despite the increase in the women’s state pension age to 65 between 2010 and 2020 and the increase for both men and women from 65 to 68 between 2024 and 2046.  In 2008 there were 3.2 people of working age for every person of pensionable age. This ratio is projected to fall to 2.8 by 2033.
Graph showing that the projected increase in the UK population 2008-2033 is concentrated in older groups

Public spending and older people

Much of today’s public spending on benefits is focussed on elderly people.  65% of Department for Work and Pensions benefit expenditure goes to those over working age, equivalent to £100 billion in 2010/11 or one-seventh of public expenditure.  Continuing to provide state benefits and pensions at today’s average would mean additional spending of £10 billion a year for every additional one million people over working age.
Growing numbers of elderly people also have an impact on the NHS, where average spending for retired households is nearly double that for non-retired households: in 2007/08 the average value of NHS services for retired households was £5,200 compared with £2,800 for non-retired.  These averages conceal variation across older age groups, with the cost of service provision for the most elderly likely to be much greater than for younger retired people.  The Department of Health estimates that the average cost of providing hospital and community health services for a person aged 85 years or more is around three times greater than for a person aged 65 to 74 years.
State benefits and the NHS accounted for just under half of government expenditure in 2009/10.  With much of this spending directed at elderly people, their growing number will present challenges for providers of these particular services as well as for the public finances as a whole.

Origins of the ageing population

The ageing population of the UK mirrors that in many other European countries.  It is partly a consequence of the age structure of the population alive today, in particular the ageing of the large number of people born during the 1960s baby boom.
It also stems from increased longevity – a man born in the UK in 1981 had a cohort life expectancy at birth of 84 years.  For a boy born today, the figure is 89 years, and by 2030 it is projected to be 91.  The trend for women is similar.  A girl born in 1981 was expected to live for 89 years and one born today might expect to live to 92.  Cohort projections suggest a girl born in 2030 might live to 95.  Healthy life expectancy has not, however, increased as fast, resulting in proportionally greater demands on public services such as the NHS.
Graph showing that centenarians will continue to be the fastest growing age group

Uncertainty in projections

There is a range of uncertainty about projecting population, as it rests on assumptions about future demographic behaviour.  The recent rise in UK fertility could be maintained, perhaps because of the influence of high levels of net migration; life expectancy might stagnate because of increasing obesity levels; net migration may fall back to levels more typical of the UK’s history if economic conditions change or more restrictive policies are introduced.  Population projections have a mixed record.  They do, however, provide a common basis of framework for planning the future across the range of public policy areas.

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