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

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