Tuesday, 9 December 2014

Liverpool Care Pathway - AC/DC

Advanced Care...
or Directive to Care less?

The old, the vulnerable, are not a nuisance but an opportunity to care. To care is a privilege.
Liverpool Care Pathway – A Loss Of Touch With the Final Reality Of Life
Disability is also a badge of pride the bearer may shame us with the merit of their courage and achievement.

Caring may humble the haughty and punish the proud. Caring ennobles the soul.

Do not raise complaint, but give thanks. To care is not a chore but a privilege and an honour bestowed upon us.
Say it loud, say it clear,
For the whole wide world to hear:
"Thankyou for enabling me to care."
[With apologies to The Lighthouse Family]
If we cease to care then we cease to be human.

The manner in which something is put may change its meaning entirely. Just as the ‘right’ to die may permit the right to kill, so a Directive to deny treatment may just simply confirm and justify its withdrawal.

The Directive imagines scenarios in which the Director decides they would prefer the ‘remedy’ for the ill or the protocol for treatment should not be applied. These are scenarios considered to be untenable but when the alternative is death is there an alternative? Doctors have means enough already to come to a determination to deny treatment and to deny life.

The Mental Capacity Act of 2005 permits doctors to act in the patient’s “best interests” and withhold all treatment when it has been adjudged that they are incapable of taking decisions for themselves. This includes withholding food and water as this, also, is a medical intervention.

This is a determination that it is in the patient’s "best interests" to die.

If families try to intervene to save their loved ones lives, social services and police can be, and have been, called to intervene.

The ACD will only make this decision easier for doctors to take and relieve them of all responsibility. In other words, let them off the hook, both morally and legally.

Barbara Wilding, Britain's longest serving female chief constable, commented that the growing public approval for ‘assisted suicide’ is a threat to elderly people and that "a growing rift" between the generations is becoming a significant challenge for police who are concerned that a relaxation of the law could be exploited by families to kill "burdensome elderly relatives".

The ACD provides the means. A Donor Codicil provides an incentive.
The key issue is that there are numerous clinical situations which mimic the dying phase, including dehydration. The hospice movement in Britain continues to teach that rehydration via a drip is rarely necessary – despite evidence from America to the contrary – and that the use of a drip "medicalises dying".

Dehydration can cause the build-up of toxic metabolites from morphine and other drugs, resulting in confusion, drowsiness and jerking or twitching. This is then often managed by sedation rather than rehydration.

When I last audited my use of intravenous rehydration in a hospice setting, 50 per cent of the patients went home – which invites the question of what happens to patients in those hospices which still refuse to offer rehydration.

The answer perhaps lies in the disturbing number of deaths in Britain following continuous deep sedation.

Dr Peter Hargreaves
Patient confidentiality

The relationship between doctor and patient has always been a special one, guided by the Hippocratic Oath, by honour, integrity and common decency. Did all that begin to go awry with the intervention of the State to create a socialised medicine? Or was it never so?

Yevgeny Zamyatin forewarned in 1924 with the publication of ‘We’, for there is only Us and everyone counts.

George Orwell warned in ‘1984’ of a Big Brother, an Auntie State intervening in every aspect of life.

Big Brother is a public guardian who knows better than we what is best for us and will take charge of us and our affairs for our own good. 1984 was 30 years off the mark and we are walking into Big Brother's world with a smile and a grin to welcome him with arms open wide.

A reality has spawned in 2014 of secret courts that mete out judgements behind closed doors and sit for our ‘protection’. Newspeak is rife and, everywhere, it is all for ‘our own good’ that we willingly submit and accept and, soon, shall leap with joy onto the Carousel, to be conveyed off into oblivion.
Liverpool Care Pathway - Data Is Power
The Health and Social Care Act 2012 affected the ways in which NHS organisations can access and process data.

During the opening weeks of 2013 came a snatch and grab of confidential patient records uploaded to a central databank.

Everyone Counts had arrived...

All NHS funded providers (including independent sector) are required to comply with data collections to a central bank, the HSCIC (Health and Social Care Information Centre).

In Primary Care, data sets developed with the help of the CCGs will be extracted from GP practices for submission. ALL patient data, including ‘identifiable components’, will be sourced and stored utilising the centrally funded General Practice Extraction Service (GPES).

Fear not citizen, the GPES is a ‘secure’ Database. The HSCIC is a ‘safe haven’. There is no exception. All data is stored...
NHS England

NHS Number
Date of Birth
Post Code
Ethnicity Code
Registration Status
Registration Date
DeRegistration Date
Date of Death

Diagnosis, referral and event data, even dietary and exercise advice are recorded.

General Practice Prescribing Data will be collected through the Electronic Prescription Service.

Pathology data will be collected through results messages sent by laboratories.

The way people are cared for and treated is being “radically transformed”. The patient is no longer the patient but part of the group. This is essential to gather and identify candidates for the lists which GP’s were also asked to draw up in 2012, the so-called 1% which some have dubbed ‘Death Lists’.

The identified patients are earmarked for downsized care. This is the patient ‘toolkit’ launched by Norman Lamb. Doctors are expected to pick out patients during routine consultations that show ‘indicators of frailty and deterioration’ and are told that ‘older people are a priority to consider’.

District nurses and hospital consultants feed back information. Patients in care homes are ‘actively considered' for the register.

Using GSF and the Barton Method, GPs identify those 'at risk' of being admitted to hospital. The GP computer system EMIS Web also identifies patients who are most likely to require an unplanned A&E admission and those with ‘multi-morbidity’.

These patients are ‘less likely to be subject to treatments of limited clinical value’.

This will save the NHS £billions each year.

This is risk stratification. You can’t dig your way out of a hole; you have to fill it in. Cutting ED attendance is key and identifying the ‘one percent’ is the combination to the lock.

PCC risk stratification
NHS England has today published advice on how to conduct risk stratification while complying with the new legal framework that exists following the implementation of the Health and Social Care Act 2012.NHS England
The Health and Social Care Act 2012 changed the levels of access to data for different commissioning organisations. This caused "significant" concerns. A NHS England Information Governance Transition Programme will “develop a range of short-term and medium-term measures to address these issues”. The Programme will also “identify the longer-term requirements to ensure that users of data within the NHS are able to access the data they need to undertake their roles in a timely, cost-effective and legal manner”.

The Act complicated the legal landscape relating to risk stratification.
Risk stratification tools typically use historic information such as age, gender, diagnoses, and patterns of hospital use as the basis of their predictions. Some models (e.g., PARR and PARR-30) use a combination of hospital data and geographical data such as the Index of Multiple Deprivation. Other models (e.g., the Combined Predictive Model) use primary care data derived from GP practice systems in addition to hospital data as the basis of their predictions.
The legal framework governing the use of personal confidential data in health care is a maze of various Acts and Regulations. These include the Health Service (Control of patient information) regulations 2002, the NHS Act 2006, the Health and Social Care Act 2012, the Data Protection Act, and the Human Rights Act.

NHS England sought and obtained transitional support under the Section 251 regulations for a period of three months for the Section 251 support previously provided to PCTs. In addition, CCGs were established as Accredited Safe Havens (ASHs) of information.

In the following letter, use of ‘pseudonymised data’ and ‘weakly pseudonymised data’ in an Accredited Safe Haven is discussed...

Hunt wants millions of private medical records to be stored and shared between hospitals, GPs, Care Homes and local councils. This is Everyone Counts: Planning for Patients 2013/14, a programme designed to extend the availability of patient data across the health service, controlled by the NHS's Health and Social Care Information Centre.

What Labour began, the Coalition has expanded upon.

Simon Stevens' Integrated NHS is already in the making.

NHS England
Data and information pooling is key. This is ‘Co-ordinated Care’. Risk assessment coupled with co-ordinated care reduces admissions. GPs, hospital and community nurses, social carers and mental health professionals all ‘securely’ share vital medical information (with patient permission) to deliver care that ensures no-one falls through the net and ends up in hospital.

Risk Assessments are formulated also sourcing available ACDs.

Beware what you wish for.

Autumn 2014 and Care Dot Data is back with a phased roll out involving up to 500 GP Practices...
In recent months, NHS England has heard from GPs, professional bodies and patient groups that more needs to be done to ensure that patients and the public have a clear understanding of NHS England’s intention to use patient data held by GP practices for purposes beyond direct health care. In particular, greater assurances are sought on issues such as patients’ right to object, protecting privacy, the burden on GPs, and the controls around how data held by the Health and Social Care Information Centre (HSCIC) will be accessed and used.

This is why NHS England announced an extension to the proposed roll out of the care.data programme, until the autumn, to raise awareness, listen and act on the views of patients and key stakeholders, and to discuss both the benefits and risks involved. More discussion, debate, reassurance and action is needed around issues such as ensuring the public are aware of their choices and are empowered to take informed decisions based upon a clear understanding of the issues. See here for details of how to get involved in forthcoming discussions about the care.data programme.
The pressure cooker is bubbling -
- London Evening Standard
With an aging population increasing demand for local services, London Councils maintained that boroughs in the capital will be underfunded by £3.4 billion by 2020.

‘Many councils will be forced to cut to the bone if the Government continues to make these levels of annual cuts up to 2020’ - Jules Pipe, Chairman of London Councils

They are ‘halfway through the cuts’.

And we are only half way there...
Liverpool Care Pathway - Active Killing...?

Liverpool Care Pathway - In The Beginning Was The Pathway...

This is the cost of living. The reckoning is coming.

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