Tuesday, 2 December 2014

Liverpool Care Pathway - Back To A Way Forward

Desperate times, desperate attitudes and desperate people: A shame on our house...

To stand by and do nothing while a wrong proceeds unchallenged is to be complicit in it. Complacency permits the unthinkable to become thinkable and the unacceptable to become possible.

A culture-shift has taken place, in the NHS, in attitudes and perceptions, across all levels. Call it spin, call it what you will, this is social engineering...

Liverpool Care Pathway - Nudge, Nudge, Say No More...
The culture-shift is planned and is proceeding...
Liverpool Care Pathway - The Bee Wee Consultation

Just make it sound desirable...

The Advance Directive has been advanced by Euthanasia 5th Columnists in Age UK and has spread into Local Government and Social Housing...

New paperwork is being introduced at our scheme...

The Advance Directive is now included to source information for risk assessments. This will impact in ways unthought-of and unforeseen upon those who have agreed or been persuaded to make them.

The fundamental instinct to rescue life is being challenged.

Whatever happened to: "Never say die!"?

Whatever happened to: "Where there's life, there's hope!"?

The Guardian reports on an Office of National Statistics finding that a fifth of certified causes of death are inaccurate.

They cannot get it right after the fact. How can they get it right up to a year before the fact?

Would you rather be a hammer or a nail...?
Liverpool Care Pathway - The Nail In The Coffin
Liverpool Care Pathway - The Shadows That Precede
Doctors are encouraged to approach the patient not with trust and hope but as a predator seeking its prey to find their one percent.

Diseases may follow clear, definable illness-trajectories; patients do not.

Even for those with a terminal illness, there are no certainties. It is for this reason that every medical practitioner should despair of the Government's policy to identify and to hunt down their ‘one percent’ for palliative care.

This is a fundamentalist Communitarianism that aims to assess the likelihood of death in patients within a time frame of one year, whatever their diagnosis. The Barton Method to ‘eye them up’, as defined in the Gold Standards Framework, is recommended for this purpose.

Patients are being treated as falling into a category rather than as individuals. Certain classes of patients are being treated like starfish left high and dry at low tide.

If they survive until the tide turns again, then...

But no effort will be made to throw them back into the water. When there are so many and such finite resources to cope, it is clear where the Communitarian line must be drawn.

Doctors used to enter their profession with an awe and a wonder at the resilience of life to fight back and to cope; armed with a respect for life defined by the Hippocratic Oath, they knew that life is precious and living matters.

The London Evening Standard reports on a 'study tour' by a delegation from Imperial NHS Trust to the East Coast funded by the DoH -

Ann Drinkell of the Save Our Hospitals Campaign responded: “I think we don’t want the American model of care, which is based on the ability to pay – not on need.”

Actually, what care or treatment is allocated to you is based not on need but a mathematical calculation.

N.I.C.E. employs a template of criteria based on "efficacy and cost effectiveness," in which a key formula is the "quality adjusted life year" (QALY). The QALY "takes into consideration the quality of life of the patient during any additional time for which their life will be prolonged". The clinical and cost effectiveness of the treatment is then used as the basis for a recommendation as to whether or not the treatment should be provided.

Other aspects of the N.I.C.E. criteria include the concept of the "cost per quality adjusted life-years gained" (CQG). The CQG examines the cost of treatment, divided by the estimated years to be gained by the treatment and creates an "overall cost benefit ratio", giving the "cost per quality adjusted life-year gained". Under this criterion, cancer treatment for a small child may deliver many more years of "quality of life" than the same treatment on an elderly patient.

'Quality of Life' is a dangerous expression. Can it be determined and is it determinable? It places those with disability at risk in a society that demands DNR decisions and may yet inflict 'assisted suicide'.

A NHS policy team has been sent to the US.

Policy sharing has proceeded and is proceeding.

The NHS is in dire financial straits. Likewise, Medicare and Medicaid are not sustainable. Both those of this and those of that political ilk each lay blame and accusation at each other's door.

Affordable healthcare does not mean making healthcare affordable but cost-effective. It means making it affordable by limiting available healthcare options.

Obama advisor,Cass Sunstein, has written in support of what some people have called the "senior death discount" which is the statistical practice of taking into account years of life expectancy when evaluating a regulation. This is key to the fundamentalist Communitarian thinking of Obamacare.

Fittingly, Sunstein has repeatedly and consistently defended the idea of a strong regulatory State. He has turned his back on the constitution of the Founding Fathers to secure the people from the State and adopts the European model.

Catch-up reading -
Liverpool Care Pathway - The Micawber Principle 
Liverpool Care Pathway - Crying Wolf 
Liverpool Care Pathway – The Protocol Of Choice
The individual doctor has always responded by treating the individual patient before them, traditionally, according to the Hippocratic Oath.

No more...

The patient is categorised and responded to accordingly rather than responded to according to the medical demands of the individual patient. The protocol of the category is easier to respond to; it is 'less fuss', less time-consuming and with 'evidenceable' outcomes.

A protocol pertaining to category removes responsibility and releases the medical practitioner from tiresome, time-consuming responsive diagnosis. The physician's time is more efficiently and economically spent.

Nothing is 'free'. Even something for which there is 'No Charge' requires the free-given effort of the charitable giver, and, let’s be clear about this, the NHS is not ‘free’. Like everything else, it has to be paid for. For some, it’s a rip-off they are paying for twice over –

Liverpool Care Pathway – Another 'National Scandal' 
Liverpool Care Pathway – By Fault, Or By Default And Design? 

Policy and design are being pooled and shared as they get back to a way forward.

According to Mr. Hunt, Local government has been squeezed by ‘tough financial settlements’.

This is HSJ –

The NHS has a responsibility to help local authorities cope with their “tough financial settlement”, health secretary Jeremy Hunt has said. 
Mr Hunt made the comments in a speech at the National Children and Adult Services conference in Manchester yesterday, according to HSJ’s sister title Local Government Chronicle.
“We prioritised the NHS by protecting its budget, which meant tougher settlements for other departments including local government,” he said.
“But the interconnected relationship between the services we both offer to vulnerable people means that we in the NHS have a responsibility, as we move to fully integrated services, to help you [in local government] deal with a tough financial settlement.

Mr. Hunt was talking about the £5.3 bn Better Care Fund to keep people out of hospitals. Health and Wellbeing Boards have been created and local authorities have been charged with greater responsibility in this area.

The Health and Wellbeing Boards have been productive in developing EoLC provision and the move to ‘respecting and acting upon’ EoL wishes - code for Advance Care Directives.

The Fund is to further enable this process.

According to the The King's Fund, the Better Care Fund has been implemented in the context of an aging population. This is spending money not to provide for demand but to reduce that demand. This is spending money to save money -
As financial and service pressures facing the NHS and local government intensify, the need for integrated care to improve people’s experience of health and care, the outcomes achieved and the efficient use of resources has never been greater.

The June 2013 Spending Round announced the creation of a £3.8 billion Integration Transformation Fund – now referred to as the Better Care Fund – described as ‘a single pooled budget for health and social care services to work more closely together in local areas, based on a plan agreed between the NHS and local authorities’ (Local Government Association and NHS England 2013).

The £3.8 billion is not new or additional money: £1.9 billion will come from clinical commissioning group (CCG) allocations (equivalent to around £10 million for an average CCG) in addition to NHS money already transferred to social care. For most CCGs finding money for the Better Care Fund will involve redeploying funds from existing NHS services. Guidance makes clear that the Better Care Fund will entail a substantial shift of activity and resource from hospitals to the community – ‘hospital emergency activity will have to reduce by 15%’ (NHS England 2013). This could place additional financial pressures on providers already facing the quandary of how to maintain and improve quality of care while achieving financial balance. In addition, the Better Care Fund does not address the financial pressures faced by local authorities and CCGs in 2015 which ‘remain very challenging’ (Local Government Association and NHS England 2013).
The King’s Fund says that the Fund consists of £3.8 bn of reallocated money.

The National Audit Office announces that the Better Care Fund will pool £5.3 bn of existing NHS and local authority funding and will run from April 2015.

What has happened?

Public Finance  explains -
Hunt said yesterday that there had been ‘remarkable progress’ in the development of the fund plans, which would be the first time anywhere in the world efforts had been made to integrate health and social care across an entire health economy.

‘Building on the excellent work by [care minister] Norman Lamb on the Integration Pioneers that many of you were involved in, local authorities and local NHS commissioners have joined together and painstakingly planned commissioning for adult health and social care with pooled budgets,’ he said.

‘Budgets from the local authority side are for the first time helping to reduce emergency hospital admissions and budgets from the NHS side are for the first time helping to reduce permanent admissions to care homes.’

He said that critics who had said the initiative was unachievable had been proved wrong, ‘because today I am delighted to announce the total amount of pooled budget for next year is even higher than the government’s original £3.8bn – it has risen to a staggering £5.3bn’.

He said that 146 of the 151 plans have been approved, with additional help being offered to the five remaining areas.
HSJ continues -
During the speech Mr Hunt said there would be “no sustainable future for the NHS without a sustainable future for social care” and there would be “no sustainable future for social care without a strong NHS”.
Mr Hunt said the fund, a £5.3bn pooled budget between councils and the NHS to join up health and care services, was “not peripheral, but central to the kind of change we want to see in our NHS and social care system”.

The Five Year Forward View published jointly by NHS England in October reflects these changes, speaking of new partnerships with local communities and of closing the projected budgetary deficit in whole or in part by 2020/21.

In response to this, the Chancellor, George Osborne, has promised increased funding, a third of which is, again, reallocated money.

The Terminator

Simon Stevens is back...

This is NHS England –
It’s good to be back – back in the NHS, and back here on Tyneside.
I know times are tough, and the Health Service is under pressure. But when people ask me why take on this new job? My answer is:  Because I believe in the NHS, and I believe in its future. That it will be there when we need it, at the most profound moments in our lives. At the birth of our children. At the deaths of our loved ones. And at every stage in between – as we grapple with hope, fear, generosity, loneliness, compassion – all the most profound elements of the human spirit.
I was reminded of this again this morning in Consett, County Durham, where 26 years ago I started work in the NHS. Obviously the hospital has changed a lot – the old Nissen hut wards are long gone, and services have moved. But the nurses and patients and GPs I chatted with on the cancer unit and rehab service had that same passion and commitment for health, and made a convincing case that the quality of care is better than ever.
And Simon has been generously welcomed back...

Polly Toynbee heaps praise in The Guardian –

Toynbee praises Stevens’ plan for its good ideas.

Toynbee writes -
Stevens’s opening eulogy to NHS principles has a passionate ring, and that’s the way he talks about the service too. He likes to quote the US Commonwealth Fund, a private health foundation and his only outside board, whose annual research puts the NHS at or near the top as the most effective, best bang-for-the-buck service in the world.
That’s no mean praise from stage left.

Clearly, the same aggressive policies of downsized healthcare provision shared by Obamacare and NHS in the pursuit of fundamentalist Communitarian policies will continue as the ‘best bang-for-the-buck’ measure to deal with the multi-morbidity ‘Tsunami of need’ referred to in the End of Life Baseline Report.

Pertinent reports -
Liverpool Care Pathway - The Communitarian Nudge

Liverpool Care Pathway - Appointment With Death
Downsizing care expectations and accepting the glass as half empty is key.

Simon knows he can make that difference...

Stevens describes the NHS as a 'social movement'. That means what it implies and Stevens' manifesto is - in Obama terminology - a living document.

Stevens understands that he is looking into the economic abyss. At such times, the audacity of hope becomes the audacity of desperation. The Communitarian demands of altered standards of care and rationing of available resources must be employed and presented favourably in a manner such that they will be accepted.

Final words -
Liverpool Care Pathway - What Prospect Does This Bode...?

Liverpool Care Pathway - The Communitarian Imperative

Liverpool Care Pathway - Living Wishes

In the Margins

The Mail reports our old ones marooned and abandoned so their families may finish their decorating and go on holidays.

The Mail reports that a ComRes poll actually found that 10% of people thought the sick and elderly should be rewarded for ending their lives. A quarter were undecided...

This ‘Tsunami of need’ is unwanted, a hindrance, a burden of bed-blockers.

In The Margins

Tuck me in
I need to sleep now
I need to dream how
I used to dream

Look me in
Look me in the face now
Help me believe how
I used to believe

Now do you see how
They're in the margins
Below and up above
I'll see now
How life wins
When all that's left is love

- Echo and The Bunnymen

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