Friday, 30 January 2015

Liverpool Care Pathway - Still Playing Games Of Consequences

When targets must be met and books must be balanced, anything is possible.

Essential EPaCCs means everyone’s on board with Care LESS.

Policies have consequences. There are always consequences.

East of England Ambulance Service logged seven 'serious incidents' in December - with patients dying in five of them.

This from Cambridge News –

The deaths came as a result of ambulance delay, hospital delay or clinical treatment.

A sixth incident involved a 'medication management issue' and the seventh relates to 'non-conveyance of a patient'.

The last one follows a complaint from the family of a dementia sufferer who said they were rudely treated by a paramedic who refused to take her to hospital.

The woman had been told she needed to be admitted by her GP but an emergency care assistant sent by a private contractor questioned the decision.

The report said: "The crew have apologised if they have caused any upset by this incident but felt that they had the patient's best interests at heart throughout their attendance."

It added memorandums have been sent to all of its independent ambulance providers to remind them they must convey the patient to the receiving destination as requested.

The identities of the other patients involved in the serious incidents which includes one near Cambridge have not been revealed. The previous month of November saw three serious incidents but the trust recorded 105 in total in 2014.

The doctor flagged for admission. Clearly, a breakdown in EPaCCs.

The Telegraph reported that East of England have a 'secret policy' to downgrade 999 calls and not send ambulances to terminally ill patients.

East of England reportedly admit that 8,000 patients have been affected by the policy and a report discloses that 57 patients died following decisions not to send ambulances to the terminally ill and to those who had given instructions not to resuscitate.

Surprise, surprise... Beware for what you sign up to.

Readers of these pages will not be surprised. These are not secret policies but an ongoing programme.

Bland, innocuous terms are used to camouflage a dark intent.

Work Makes Us Free!

Will they dare dot DATA?

George Murgatroyd is head of intelligence for Dr Foster. George compares the NHS with NASA in an article in HSJ 

Both are public sector organisations that are totemic in the minds of their respective nations. Both are highly respected internationally. And both are sitting on vast stores of data with the potential to help solve problems affecting all mankind.

Over the past five years, this initiative has invited coders from around the world to develop open source software solutions to everything from landslide predictions to public sanitation.
George wants collaboration on DATA. Sharing and collaboratively harnessing data can save lives, he says. Wait a minute...

There is data and there is data...
Liverpool Care Pathway - Data Is Power
For instance, collecting personal data for reasons of diversity and inclusion of ‘minority groups’ might appear innocuous, commendable even; in the wrong hands, such information, so readily accessible, might be applied for far less laudable ends, however. The easy availability of such data would have been very useful to a certain gentleman to pursue his Final Solution.

Both organisations are subject to political control. Both may cancel and ration at a politicians whim. And politicians are not generally renowned for their altruism.

This is the Telegraph 

Eight thousand cancer patients are likely to have their lives cut short following a decision to withdraw NHS funding for 25 treatments.

Medication which offers a last chance to patients with cancer a year - including those with breast, prostate and bowel disease - will no longer be funded by the NHS, under plans to scale back spending from April.
Running round in circles

Jeremy Hunt wants all medical data online and for the NHS to be "paperless" by 2018. Digital records will be shared at the touch of a button. Health and social care services, from ambulance workers to hospital consultants to care homes for elderly people will have access to those ACDs.

Whether Policy, Programme or Grand Plan, it will serve as a Super Electronic Palliative Care Co-ordination System (EPaCCs) and save £5bn a year.

The Guardian
Health and IT professionals remain deeply sceptical that the NHS can be paperless by 2018, two years after health secretary Jeremy Hunt unveiled the ambitious target, exclusive HSJ research has found.
The government has raided a £240m NHS technology fund to bolster financial support for hospitals struggling with accident and emergency demand this winter, senior sources have told HSJ.
What will they dare...?

A Medical Innovation Bill is now proceeding through Parliament. Is this 'innovation' or experimentation?
Liverpool Care Pathway - Somewhere... Is There Erewhon?
According to the NHS England Business Plan 2015/16 -
We will act as a facilitator of research – for example, we are planning to investigate a system of ‘presumed consent’ to take part in research studies for all patients treated in teaching hospitals.
NHS England Business Plan 
...a policy of presumed consent is being investigated.

The NHS operates a policy of non-exclusion. To ensure that no-one shall be excluded from this 'presumed consent' system, hospitals are being given 'University Hospital' status.
university hospital is an institution which combines the services of a hospital with the education of medical students and with medical research. These hospitals are typically affiliated with a medical school or university.
The focus of any health provider is to restore the patient to a condition of health. A healthy population is constructive to maintaining and encouraging a healthy economy but that is an entirely incidental consequence.

We are nearly there.

Monday, 19 January 2015

Liverpool Care Pathway - 111, EPaCCs And The 999 Downgrade

ACDs: Is the final solution, centrally driven, after all, the Final Solution?

Pilots have been run aiming for DIUPRs (Deaths in Usual Place of Residence) as part of a ‘final solution’ to end clogging of the EDs. The Care LESS system was developed to this end.

The Death Lists were crucial along with an appropriate name to ease sensibilities. At Brighton and Hove, this was the web-based ‘Share My Care’; in London, ‘Co-ordinate My Care’.

This is the sort of thing that the dodgy pro-euthanasia group Dignity in Dying (funded by the National Lottery) have been promoting alongside the appropriately groomed Age UK (via their Grooming the Groomer programme) to groom vulnerable elderly folk to sign up to via ACDs.

At Brighton & Hove...
4.2 Cost benefits
The ambulance is summoned. 
Ambulance staff access the Care LESS. 
GP service is contacted. 
Home palliative care team responds.
Liverpool Care Pathway - The Devil Is In The Detail
The EPaCCS are essential and integral to the final solution. Clearly, something is going wrong.

According to Ely Standard, Addenbrooke’s has recently declared a ‘state of emergency’ -
The hospital was dealing with especially high numbers of frail elderly patients combined with a record level of patients whose medical care is finished and whose discharge is delayed.

Liverpool Care Pathway - So This Is New Year...

This is NHS 111: getting lost in translation?, an NHS Alliance Discussion Paper from the Clinical Commissioning Federation and the Urgent Care Network
 Some systems are introducing ‘Call before you go’ so that patients, who for whatever reason choose to visit A&E can be offered a community based alternative, when appropriate. Encouraging patients to call NHS 111 rather than just turn up at A&E and, if suitable, directly setting up an appointment with their practice is another option for local commissioners.

 In London CCGs are working together to develop a single electronic end of life register for London as part of a project called 'coordinate my care' (CMC). Once NHS 111 is live in London, patients or carers calling 111 will be flagged as having a CMC entry, the entry will be opened and the agreed care plan can then be implemented. The plan would then be to extend this to other patient groups over time, for example, for the care of patients with long term condition or patients with a mental health crisis.

The clinical NHS 111 leads are currently producing a list of potential service innovation that moving to an NHS 111 service offers and they will be sharing this soon.

These examples highlight the potential to use local flexibility within the national framework. But at the same time we need to acknowledge that many CCGs are reporting that they are facing considerable pressure to sign up to models that offer very little room to develop and use these flexibilities. Too many feel that this is top down politics, implemented by an NHS management system that is required to meet tight timescales on central priorities, even if this is not the government’s intention.

The clinical imperative is centrally driven.

Comments include -
“I have strong reservations about 111 - the whole of the NHS reforms are being managerially-led and the clinically-led proclamations seemed to have been purely an aspiration which has now been all but sadly lost.” Another respondent said “We started by considering a local pilot, but have been told it’s too much of a risk. The timetable for implementation is clearly driven from the top. We now must devote resource to ensuring its not going to destabilise our local urgent care strategy.” Another respondent focussed on a specific aspect of the programme “the centrally defined governance arrangements and assurance processes are horrendous, and the lack of local  flexibility is antithetical to the supposed local freedoms of the new NHS”.
Now, Pulse reports that NHS 111 provider Care UK has apologised to GPs and offered them administrative support in updating their patient records after a technical fault meant 15,000 NHS 111 non-urgent post event messages were not received by practices...
The problem, which affected some calls from April until October 2014, resulted in 15,000 cases where the registered practice did not receive a record of the calls, which were all closed without the need for further intervention.

Care UK has told Pulse they immediately notified CCGs and NHS England when the fault was identified, that the assessment by senior clinicians indicates patients weren’t put at risk as a result, and that measures have been put in place to prevent a repeat.

After every call to NHS 111, the provider is meant to send a post event message detailing the call, even when there was no need for any action.

The ‘risk’ is that patients earmarked for Care LESS might be referred for care more to hospital...
Dr Mann quoted figures showing there had been 450,000 extra A&E attendances in the past year, which could almost all be put down to NHS 111.

He said: ‘This may be an inappopriate point to point out but the reason that these people are attending our emergency departments is because we have told them to.

‘The NHS 111 figures are very interesting. Of the 450,000 extra attendances in the last year, 220,000 were advised by NHS 111 to come to the emergency department and for another 222,000, an ambulance was dispatched to them by NHS 111.

‘If you put those figures together you have more than 95% of the rise in type 1 attendances. So I don’t think we should blame people for going to the emergency department when we told them to go there. It’s absurd.’

The EPaCCS are essential and integral to the final solution. Clearly, something is going wrong.

And Pulse reports a 999 solution to the NHS 111 lack of thorough EPaCCs linkage -
NHS England is to trial giving 999 call handlers an extra two minutes to decide on whether to send out an ambulance, in light of the last two months’ ‘unprecedented’ demand on the service.

The London Ambulance Service NHS Trust and South West Ambulance Service NHS Trust, which together cover a population of around 13 million people, will begin the trial in February with the potential of measures being rolled out nationally if deemed a success in reducing the number of ambulances dispatched per call.

In today’s announcement, health secretary Jeremy Hunt said he made the decision to launch the pilots ‘in light of the unprecedented increase in demand for ambulance services in the last two months’, and after asking NHS England ‘to consider whether there were any changes which could be brought forward quickly’.

Under the current system, 999 callers are given 60 seconds to assess the patient’s need before the clock starts ticking on how long it took to dispatch the ambulance - measures that are used to assess the effectiveness of the target.
A target-driven approach results in a downgraded response service. A single paramedic may be sent out in a response vehicle. The imperative is the target, not the patient. We have had personal experience of this.

In 2005, after coming home from work, my brother became unwell. An ambulance was called. A paramedic in a car turned up. It was only when my brother began projectile vomiting a full half an hour later that the paramedic took it upon himself to summon a proper ambulance which belatedly rushed him to hospital with a brain haemorrhage. Our mother and I pursued a long and arduous complaints process via the Trust and the Ombudsman service which included the ‘treatment’ which John subsequently received. This got absolutely nowhere.

But the final solution, centrally driven, is the Final Solution which has directed the medical holocaust that has proceeded, from the formal (The Pathways such as the discredited - for now* - LKP), to the casual...

This from 2010 -

Herald Scotland
One of the country’s leading health campaigners has urged the Scottish Government to urgently tackle the problem of malnutrition of the elderly and vulnerable in the nation’s hospitals, likening the problem to a form of “euthanasia”.

Dr Jean Turner – executive director of Scotland Patients Association (SPA), a GP and former independent MSP – warned that hundreds of patients, particularly the elderly, are languishing in hospital beds undernourished because they are not given help with feeding.
Published in Medicina Paliativa –

'Implementation of the Liverpool Care Pathway' is still available and current on the Pallium Institute website. This is 'LCP in Argentina: Time to Build the Bases to Make a Difference' -
The Liverpool Care Pathway (LCP) will be a guide for us to focus on the care of the dying, providing high quality end of life practice. Excellence in care provision is based, not only on its institutional framework but also on its cultural context.
The purpose of this presentation is to show the process we started at two teaching hospitals and the NGO Home PC Program. After a retrospective base review audit (n 60) to establish our current status on the documentation of care, we translated and adapted the LCP to our environment. We realized the lack of the best practices in almost 65% of the goals of excellence from LCP. These outcomes showed us that the LCP should reinforce the education programs for care of the dying and should be incorporated within the culture of the organization. We started working in a pilot implementation called PAMPA. Our challenge consists of the use of the LCP in our clinical setting, our language and our cultural context. This requires continuous insight, critical decision making and clinical skills.
* Ray Bunn has stepped out the closet to declare himself an ‘Aye’! This from the Pharmaceutical Journal –

An expert palliative care pharmacist has come out in defence of the Liverpool Care Pathway at the Clinical Pharmacy Congress, which took place last week in London (26 April 2014).

Ray Bunn, community and specialist palliative care pharmacist, Kamsons pharmacy and St Catherine’s Hospice, Crawley, told participants: “Despite adverse publicity in the national press, I firmly and passionately believe that this particular protocol is a good thing.
* Published in BMJ Supportive & Palliative Care in November –

* The Wee Bee Long attended with the Chairman Ellershaw and the Neuberger to give keynote addresses at a Central London event last Tuesday [Westminster Health Forum].

And this is 2015...

And we are nearly there

Tuesday, 13 January 2015

Liverpool Care Pathway - ‘Hands On’ Life Café

When every heartbeat counts, do you check what's on the EPaCCs or do you just plunge in and try and save that life?

Vinnie showed us how with his no-holds-barred ‘Hands On’ technique...
Liverpool Care Pathway - The Meaning Of Liff Café
Let’s do some ‘Hands On’ Life Café, because that life is exactly that: it is precious. Once lost, it is gone forever and living matters!

So, Vinnie showed us how.

Now, St. John Ambulance show us the ‘Hands On’ technique to save a choking baby's life.

A special preview of our new life-saving ad - The Chokeables

Here’s the all star line up: 

David Mitchell - Pen Lid Johnny Vegas - Jelly Baby David Walliams - The Princess Sir John Hurt - Peanut 

The celebrities each take on the voice of an animated object that could potentially choke babies. They want to show you how easy it is to save a choking baby’s life

The Chokeables TV ad will air tomorrow - you can watch it first here.

Get behind it - tweet #thechokeables. Share with friends, family and everyone you know, so that more people know how to save a choking baby’s life. 

We’re only able to carry out educational campaigns like this thanks to the support of our customers. 

Thank you. 

P.S. If you’d like to spread the word within your organisation, please email us for a package of resources.

St John Ambulance #TheChokeables advert: save a choking baby

Following up on ‘Hands Only’ the British Heart Foundation are pushing their Call Push Rescue model -

As there's a benefit in giving rescue breaths, our new Call Push Rescue training model teaches how to do it. However, if you’d prefer not to give rescue breaths Hands-only CPR is still likely to increase a person’s chance of survival and it’s definitely better than doing nothing.

Call Push Rescue - Learn CPR trailer

'Hands On' Save a life; do not adjudge a life to be lacking quality...
Liverpool Care Pathway - The Joy Of Living 
Liverpool Care Pathway - The Final Repose

Friday, 9 January 2015

Liverpool Care Pathway - So This Is New Year...

Another year over,
And a new one just begun...

So this is New Year...

This is Ely Standard –

Chief executive Dr Keith McNeil said that the hospital has been under “extreme pressure” since New Year’s Eve and “for the past two days we have been in critical internal incident mode”

He said that as of 7pm last night the hospital had declared “a major incident due to unprecedented levels of demand on our services.”

The hospital was dealing with especially high numbers of frail elderly patients combined with a record level of patients whose medical care is finished and whose discharge is delayed.
“As part of our plans to manage high demand on our services, we have cancelled all non- emergency surgery and procedures. Right across the country the situation is similar. Ambulance and community services are also under pressure and this has put additional pressure onto acute hospitals.”
Aiming for the DIUPRs...

EPaCCS are essential and integral to the final solution.

The report describes “The quantitative analysis undertaken as part of the evaluation, focusing on national data for deaths in usual place of residence (DIUPR), local information on EPaCCS costs, and data extracts from EPaCCS and Hospital Episode Statistics.”
Because of the progress made in Locality D, as well as it being the location with the longest development path, it is worth describing more of the local context as an indication of the potential extent of the whole system changes necessary to realise the benefit seen there. The elements of development that support the high score against the critical success factors include:
-  Advanced Care Planning was made mandatory training before users of the system received their login details and was also rolled out in care homes;  
-  There is automatic flagging to 111, 999 and GP OOH for all 24/7 services;
-  Nursing home training has been prioritised with a number of routes to training, including provision by the hospice;
-  EoLC facilitator roles are in place and working with acute hospital discharge teams;
-  Extensive training continues to be provided on a ‘train the trainer’ basis across the locality.
This location is also now progressing to implement a new LES scheme and recently introduced two CQUINs in both the community and the hospital sectors. These will not have had an impact on the progress reflected  in this evaluation but demonstrate the ongoing progress that needs to be made as they enter their third year of EPaCCS.
So this is New Year...

This is Ely Standard again –
The CQC, which inspected the hospital in September, released its report into standards at the Huntingdon hospital today (Friday).

Inspectors say that three of the five categories – are services safe, caring and well-led – were inadequate and the remaining two – are services effective and responsive – required improvement.

As a result, the CQC has recommended Hinchingbrooke be put in special measures and its breaches monitored by the Trust Development Authority (TDA).
Concerns are raised about drinks being placed out of patients’ reach and the response to call balls on a number of wards that, in some cases, was so bad that two patients said they were told to soil themselves, and another soiled themselves waiting for a nurse to come.
Well, sadly, that sounds depressingly all too familiar.
Ely Standard continues –
Other key findings were:

• Many instances of staff wishing to care for patients in the best way, but unable to raise concerns or prevent service demands from severely impinging on the quality and kindness of care for patients. In both maternity and critical care we noted good care, focused on patients’ needs, meeting national standards.

• There was a lack of paediatric cover within the A&E department and theatres that meant that the care of children in these departments was, at times,increasing potential risks to patient safety.

• There was a lack of knowledge around Adult Safeguarding procedures, Mental Capacity Act and Deprivation of Liberty processes.

• Infection control practices were not always complied with in A&E Apple Tree ward, Cherry Tree ward, Walnut ward and in the Treatment Centre.

• Medicines, including controlled drugs, were not always stored or administered appropriately in A&E, Juniper ward, Apple Tree ward or Cherry Tree ward.

However there was some praise for the maternity and critical care wards, with staff focused on patients’ needs and inspectors singled out the paediatric specialist nurse in the emergency department and the chaplaincy staff for their work.

The inspectors raised 21 areas of poor practice the hospital needs to make improvements and a further 12 recommendations.
In this election New Year, this is going to be kicked around as a political football by all engaging parties.

In this election New Year, this is going to be a game of ping-pong to allocate blame...
Liverpool Care Pathway - Time To Wise Up
In this election New Year, this is Ely Standard yet again with Circle Chief Exec, Steve Melton –

Can I start by thanking the staff for their professionalism and dedication.

Since we took on Hinchingbrooke in early 2012, the hospital has been transformed. Hinchingbrooke faced closure. It was described as a ‘basket case’. We invested in the quality of care, in staff and in facilities. Now, it has won a number of awards. We consistently hit the most important outcome measures, including low mortality rates, excellent patient feedback, and meet all major waiting time targets. In the first two years of the franchise, we made financial savings significantly above the NHS average. We have saved the taxpayer around £23million in total.
So, what happened and why is Melton running away? Is this the criminal escaping the scene of the crime?

The business model has been criticised and the Union has condemned private involvement.

Is the Trust trustworthy?

On record, in their own words...

Or was it all their Master's Voice...?

Melton and Circle will be accused of walking away with a nice stash.

So, what about Nicholson...?

According to Hinchingbrooke –
Our executive board is made up of nine practicing clinicians, elected by their peers and supported by four managers. These clinical leads are each responsible for a clinical divisional unit and are accountable for their own budget and their team, reducing the gap between our Board and our frontline staff.

Not only this, our organisation’s vision was written by our people, and it was our people that set our goal to become a top ten district general hospital – in fact they wanted us to be number one. To make their vision a reality, 1200 of our staff came together to shape our business plan and we captured their ideas under four simple headings: clinical outcomes, patient experience, value for money and engaged staff. And so, our 16 point plan was born, a simple pocket-sized guide to realising our goals. You can read it here.
We're part of something new, a unique franchise with a private sector company. Find out more about our partnership with Circle here.
Just down the road at Addenbrookes they're dealing with
especially high numbers of frail elderly patients combined with a record level of patients whose medical care is finished and whose discharge is delayed.
The End of Life Baseline Report published in 2011 warned of a "Tsunami of need" -
Our population is getting older and sicker. Currently there are around 1.5 million people with long term conditions living in the North West; it is estimated this figure will be 3 million by 2030. In tandem with this, population statistics estimate that the people over the age of 65 will increase by 252% by 2050; described by Sir John Oldham as “a Tsunami of need”.
Is the "Tsunami of need" breaching the gates?
Liverpool Care Pathway - Appointment With Death

Liverpool Care Pathway - Back To A Way Forward
Is the Final Solution the only solution? A medical holocaust has proceeded...
Liverpool Care Pathway - As If We Didn't Know

Liverpool Care Pathway - Persons, Personhood And Non-persons
So this is New Year, just barely begun...

Concluding reading -
Liverpool Care Pathway – The Nuremberg Pathway