Sunday, 14 June 2015

Liverpool Care Pathway - The Terminator

Dotting the 'I's is crossing the 'T's but dotting the Data is crossing the line. is back. And it's all got to be sewn up by 2020.

This is Healthcare Efficiency Through Technology –
The controversial project is set to restart later this month. Information and opt out forms are due to be sent out to patients in one of the pilot areas.

Blackburn with Darwen Clinical Commissioning Group said it will start sending letters at the end of June, with data extraction likely to take place between September and November.

The NHS England led project, which intends to link patients’ GP and hospital records, initially intended to begin extracting data in autumn last year, but the programme has been dogged by concerns about patient confidentiality.
This month the data harvest will resume. The NHS highwayman will come knocking at surgery doors to stand and deliver patient records unless you have taken the time, the trouble and the effort to opt out.

Government policy is that by 2020, in relation to data sharing, the NHS will be consent-based. That is misleading; it is presumed consent that is meant.

Long before a legal ‘Data Protection’ there was honour-bound patient confidentiality. That is all now surrendered to the huge unknowns of the big data-gulper that is

Blackburn with Darwen CCG says

Due to pre-election guidance that the CCG has had to adhere to, no communication with the public has taken place, and GPs have not been able to carry out any formal work on the programme. However, work has continued within the national programme team and with the four pathfinder areas (Blackburn with Darwen, Somerset, Hampshire, and Leeds) on the review of patient facing materials - such as the Practice Toolkit. CCGs have robust plans for their work programme and for communication with their communities.
Blackburn with Darwen will be ready to start fair processing (the time patients have to make a decision whether to opt out) at the end of June; Somerset and West Hampshire wish to start at the beginning of September. Leeds have not confirmed when they will commence testing communications but are also working towards the beginning of September. A total of 104 practices across Blackburn with Darwen, Somerset and West Hampshire have signed up.
Formal accountability for proceeding with the Programme sits with the SRO (Senior Responsible Officer), Tim Kelsey. No data will be shared until Dame Fiona Caldicott advises she is satisfied with the programme’s proposals and safeguards. Extraction is likely to take place between September and November depending on how fair processing testing communications was conducted. GP systems are currently undertaking the work required for extraction to take place.

Kelsey is NHS England's National Director for Patients and Information.

The programme will push the NHS towards a ‘consent-based’ model of data sharing by 2020, but 100 per cent security of patient information can't be guaranteed, and the 'SRO', Tim Kelsey, actually concedes no data can ever be absolutely secure.

Society is working toward a position of presumed consent: Presumed consent in organ harvesting; presumed consent in data harvesting.

You; yourself; your information: these do not belong to you, for you are We and the social composite is paramount over self.

Democracy is being turned inside out and on its head. The Communitarian ethos has taken over.

When everything becomes subordinated to a greater folly that is an ill-defined or non-defined ‘greater good’ we risk losing sight of the debt of compassion and service we owe to the individual.

The whole is only ever the sum of its parts. It is the integrity of those parts that defines the whole. We lose sight of that at our peril for in so doing do we sell our souls to serve the Devil that leads the herd.

This is a policy paper, Personalised health and care 2020, from the DoH and the NIB (National Information Board) 
The paper discusses the processes that have driven change in transacting exchange and purchase from paper to virtual transactions online.
Any proposition for closing the gap that is forecast between available resource and predicted demand, assumes significant cash releasing and efficiency contributions from technology and data services – and recent research commissioned to support this framework suggests that the potential cost-saving is substantial.
The paper employs much jargon. Realistically, it is pointing out the gap between expected demand and available supply and how that is to be closed.

In discussing these processes of change, the paper continues:
These processes or drivers of innovation – the changing of consumer behaviour driven by the ability to complete useful transactions and the transfer of skills and costs – require the affected industries to adopt particular and common characteristics.

One compelling characteristic underpinning these processes is standardisation: standardisation of processes, datasets, platforms and interfaces. In some cases the standardisation is formal, with the mandatory adoption of industry-wide standards. In other cases standards evolve through convention and informal adoption. Standardisation enables innovation, reduces development costs, lowers barriers to user adoption, speeds up wide-scale adoption and supports an almost infinite variety of bespoke and personalised service offerings.

The one compelling characteristic is ‘standardisation’.

The paper provides what it considers an illustrative example to support what is being proposed:
In the UK, heart surgeons have shared data on their individual outcomes for the last decade – and mortality rates in some procedures have fallen by a third, with around 1,000 fewer avoidable deaths each year reported. 
The Telegraph  reported -

Surgery death rate 'twice as high as thought'

Twice as many people die after surgery in NHS hospitals as previously thought, according to a new report that finds serious shortcomings in the way many patients are treated.

The overall chance of dying within two months of surgery is one in 28 (3.6 per cent), found the study published today (Fri) in The Lancet.

Dr Rupert Pearse, who led the research, described its findings as “very worrying” and said many patients were simply not getting the care they should. “We need to act,” he said.
Actually, and it should be a no-brainer, but the study published in the Lancet and reported in The Telegraph actually does confirm to be the case that better care means better outcomes.

Patients undergoing specialist surgery are treated differently, for example by dedicated teams on dedicated wards. Dr Pearse argued that meant they essentially received better care.

He said the mortality rate among adult cardiac patients was now less than two per cent - even though they tended to be older, have worse health, and require more dangerous surgery than average.

Cardiac patients are treated by specialist teams of surgeons and anaesthetists and cared for by specialist nurses on dedicated wards.

“If we did the types of things that we did in cardiac surgery, in all types of surgery, outcomes would improve.

“With most surgery, the only thing that’s different is the surgeon. But this ‘one size fits all’ approach to care isn’t really working for the overall surgical population.”

Patients were also being sent back to general wards after surgery rather than critical care beds because of a “one-size fits all” approach that was “ingrained” in the NHS.

Better care from dedicated teams means better outcomes. You don't need a central database for that.

The policy paper pushes for standardisation but the “one-size fits all” approach “ingrained” in the NHS isn't working. The paper highlights bespoke delivery of requirements online in other areas and suggests that this will translate into delivery in the medical field also.

However, whilst hospitals need to improve care for “high risk” patients, such as the very old or those undergoing dangerous procedures like emergency bowel repairs, who account for 80 per cent of deaths, doctors concede that there is simply not the money to provide such a level of care for all patients.

Risk Stratification

This is not risk stratification of data; this is risk stratification of outcomes.

The 'Surprise Question' - the GSF Barton Method - already picks these patients out as subjects for downsized care options and such treatments and procedures are identified as being of limited clinical value.

A relatively small number of patients accounts for a disproportionately large fraction of health care costs. In England, roughly half of all hospital bed-days are attributable to just five per cent of the population.

In that respect, a central unified Health and Social Care database does facilitate identifying this one percent singled out for EoL registers and the five percent of bed blockers and leaves far less to chance.

It does give the client base with the biggest clout, sailing high on the Complete Lives curve, the biggest voice through access and accommodation of need. It's all win all round.

A central unified Health and Social Care database does enable ready identification of particular groups of patients and ready provision of recommended treatments for the group.

Statisticians will be better equipped having access to a vast database to make predictions in real time of likely outcomes and forward projections...

as the climate data given a polish that came out of the University of East Anglia, perhaps.

Bigger does not mean better. What is on the system is only what is entered onto the system. Linked up systems may only provide more rapid contagion of error.

Beware, also, what you enter onto your AD that it will be available to the paramedic first responder.

When ADs are become good practice, DNRs are become practice.

Some further reading -
Liverpool Care Pathway – Joining Up The Dots

Liverpool Care Pathway - The Three Options: A Post-modern Fairytale
Some say that living longer is not the same as living well but in an environment in which cost counts and the alternative is not living at all then what are they saying?

When the impact of treatment is weighed against the impact of cost and is found wanting it is important to consider carefully the implications of what is being said before committing to a policy of treatment denial because treatment is considered of ‘limited clinical value’.

Sympathy, empathy, kindness and care cannot be equated with the taking of life that is Compassion in Dying.

There is always a paper trail, but can that be lost in the digital footprint?

Blog Supplemental –
Liverpool Care Pathway - Threshing The Data

Liverpool Care Pathway - Fracking The Data

Liverpool Care Pathway - It Cast Its Shadow Long

Liverpool Care Pathway - Be Not Disarmed By The Caring Smile

Liverpool Care Pathway - A Data Bonanza

Liverpool Care Pathway - Data Is Power

Liverpool Care Pathway - Still Playing Games Of Consequences

Thursday, 11 June 2015

Liverpool Care Pathway - 'Joined Up' Services

Risk Stratification and the one percent.

Richard Humphries has blogged and banged away about the £3.8 billion Better Care Fund. This is a pooled budget for health and social care. He now co-authors a report for the King’s Fund proposing a unified budget for Social Care and the whole NHS with the premise that what works on a small scale works even better on a bigger scale... 

This is LGC 

The study, which has been shared exclusively with LGC and its sister title Health Service Journal, also recommends that the Department of Health be given control of the national budget for social care.
Options for Integrated Commissioning follows on from last year’s Barker Commission, through which the think tank examined the financial viability of the health care system.
The new report concludes:
  • There should be a fully pooled health and social care budget in every area by 2020.
  • Local NHS and council commissioners should agree who should be in charge of this budget by 2017.
  • CCG and councils should be allowed to take control of the single budget, but health and wellbeing boards are not fit for this role in their current form.
  • The government should consider legislating to allow a new form of health and wellbeing board to take over health and social care commissioning.
  • The national social care budget should be transferred from the Department for Communities and Local Government to the Department of Health, to create a single fund for the entire service.
  • Central government should establish a single “outcomes framework” setting out what an integrated health and social care system should aim to achieve.
James Churchill steered ARC (Association for Real Change) for more than two decades. He saw “escaping from the clutches of the NHS” as one of the major achievements of learning dis over the last quarter century.

He has expressed concerns about health taking social care back into its fold...

See -
Liverpool Care Pathway - Transformation
In an open letter to David Cameron, Jan Tregelles, Mencap's acting chief executive, said -
After the exposure of abhorrent abuse and neglect at Winterbourne View Hospital in 2011, the government assured us they would use the scandal “as a spur to make things better.” Three years later nothing has changed, but we now know the scale of the problem - that 3,250 of our brothers, sisters, sons and daughters remain in units often far from home, where they are frequently over medicated, restrained and kept in solitary confinement.
We are devastated at the appalling failure of the NHS, local authorities and the government to meet their own deadlines for moving people with a learning disability out of places like Winterbourne View. It is unforgivable that the number of people going into these places is in fact going up.

This breaks a promise made to the families of people who have faced abuse and everyone who watched Panorama and demanded change. But most of all, it is a betrayal of our loved ones who remain in these units, at risk of abuse and neglect, isolated and away from their families.

The time for talking and excuses is over. You must take personal responsibility and address this failure of national government, local government and the NHS.
In another letter to supporters, Jan Tregelles remarked:
As the war ended and Churchill turned off the lights in the War Rooms for a final time, the journey to change society we live in began. Since the global financial crash of 2008, we have witnessed huge cuts in public spending - both in the form of central government grants to local authorities for vital services like social care, and also central government spending on social security. The majority of cuts are still to come, with more planned by all the main political parties after the general election. This means the environment we work in is more challenging than ever. At Royal Mencap Society we have also been hunkered down in our own bunker working out how we can win our own war on inequality.

In Mencap, Jan Tregelles reported -

New research by Mencap highlights the scale of discrimination faced by disabled patients in the NHS, following the publication today of shocking findings from an independent Inquiry into deaths of people with a learning disability.

Mencap has backed calls for the Government to set up a national body to monitor and investigate the deaths of people with a learning disability, as its research highlights that over a third (37%) of deaths of people with a learning disability are due to them not getting the right health care.
Twelve hundred excess deaths.

Nazi propaganda against the disabled and disadvantaged regularly labelled them “life unworthy of life” or “useless eaters” and highlighted their burden upon society.

An outcome of this was the T4 Programme, code for Tiergartenstrasse 4, the co-ordinating office in Berlin.

At Royal Mencap, they are hunkered down in their bunker working out how they can win their own war on inequality.

Jan Tregelles says this is: “A scandal of avoidable deaths on the scale of Mid-Staffs.”

That is not merely thought provoking; that is disquietingly concerning.

People with learning disability are also more likely to have a DNR (Do not Resuscitate) slapped in their file. Why?

Are they “life unworthy of life...”?

Are they “useless eaters...”?

The Advance Directive is now considered ‘good practice’.

The Advance Directive is to advance the Hobson's Choice of DNR.

New tick box documentation sources the Advance Directive for information to assess risk management...

This is not a good way forward.

'Broken promises'...


And this is the latest from the Lincolnshire Echo 

A patient who was cared for at a Lincoln disability centre that's currently under police investigation has died.
Long Leys Court learning disability inpatient unit was closed earlier this month due to concerns around the quality of care being provided.
Now, the trust that runs the unit has confirmed that a patient who was recently cared for there has died - though they say the death is not linked to the investigation.
A spokesman for Lincolnshire Partnership NHS Foundation Trust said: "We can confirm the extremely sad news that a Lincolnshire Partnership NHS Foundation Trust patient, recently cared for at Long Leys Court, sadly passed away on Monday, June 8, following a short illness in the acute hospital.
"We extend our most sincere condolences to the person's family and friends at this very distressing time.
"The patient was not related to current police investigations, however as necessary in such unfortunate circumstances, we must now await the outcome of any investigations surrounding their illness and death.
"We will also continue with our own internal inquiries, and therefore it is inappropriate for us to comment further at this stage."
Police reviewing 'serious incidents'
Lincolnshire Police say they are deciding whether an investigation is needed into 'a number of serious incidents' which has seen a learning disability inpatient unit closed in Lincoln.

Lincolnshire Partnership NHS Foundation Trust closed the Long Leys Court site temporarily, saying they were concerned about the alleged incidents.

No new admissions are being taken and existing patients are being discharged or transferred out of the unit.

A force spokesperson said: "A number of separate incidents have been brought to our attention which are of potential concern.

"Each incident is being assessed to see if any investigation is warranted."
Lincolnshire Partnership NHS Foundation Trust (LPFT), alongside South West Lincolnshire Clinical Commissioning Group (CCG), have taken the decision that all new admissions should cease and say that once existing patients have been discharged or transferred the unit will close.

A release to the media reads: "We would like to apologise to the patients, carers and families who may be affected by this decision and reassure everyone that this decision has not been taken lightly.
"Both the Trust and Commissioners share the view that this temporary closure is in the best interests of people with a learning disability, who often have complex needs and for whom we have a duty to ensure that the care they receive is of the highest quality," it read.

The temporary closure will enable a revised service model to be put in place for the future, with a greater emphasis on community provision and less dependence on bed based care.

The trust and commissioners have been working closely for some time to ensure that people with a learning disability are only admitted to an inpatient unit when absolutely necessary.

This work known nationally as "Transforming Care" has meant that a significant number of people who received treatment in an inpatient unit have been supported to move to much less restrictive environments more quickly.

This has significantly reduced the demand in Lincolnshire for inpatient care.

LPFT runs a number of community services for people with learning disabilities at Long Leys Court, including Community Assertive Support; these services will not be affected by this temporary closure.
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 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’. Certain groups are prioritised for consideration. Such patients are ‘less likely to be subject to treatments of limited clinical value’.

Twelve hundred excess deaths or making quality of life judgements and limiting treatment of limited clinical value?

This is risk stratification. You can’t dig your way out of a hole; you have to fill it in. Cutting ED attendance and emptying the beds 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
A relatively small number of patients accounts for a disproportionately large fraction of health care costs. In England, roughly half of all hospital bed-days are attributable to just five per cent of the population. Risk Stratification is sifting out these high-cost individuals and saving money by downsizing care expectations.

There is both reason and purpose to Transformation.

Further reading - 
Liverpool Care Pathway - Back To A Way Forward 
Liverpool Care Pathway - AC/DC

Monday, 8 June 2015

Liverpool Care Pathway - The Great Cash And Grab

who does monitor the monitors and the monitors of monitors?

The CQC has come under fire...


The CQC was shot down by an internal whistleblower claiming the monitor gave a prior nod and a wink during a tendering process.

This involved a contract worth £1.5 million.

The tendering was to look into a ‘risk based intelligence’ approach to prioritising inspections.

This followed and was a response to the Francis report, which found the CQC guilty of catastrophic failures to properly execute its duties at Mid Staffs.

According to Dave Behan, CQC CEO, in true NHS fashion, the CQC will be taking learnings.

Onmedica says –

Allegations were made that the CQC breached procurement rules during the tenders, attempts had been made to “bully and intimidate staff to select McKinsey", and that the firm had been verbally awarded the contract in advance of the procurement and given preferential treatment. However, the review found no evidence to substantiate allegations of bullying or of a verbal contract.
Is there no smoke without fire?

Does accusation insinuate implication and who does it implicate?

It has become practice to reward, as at Mid Staffs.

Despite bullying and harassment allegations, former CQC chair, David Prior, is now a government minister.

Despite suggestion that David Behan ordered the deletion of an incriminating email, he is now himself CQC CEO.

Make of that what you want and many will.

Further reading -
Liverpool Care Pathway - Who Monitors The Monitors And The Monitors Of Monitors...?
Simon Stevens' 'way forward' is supported by the £200m Transformation Fund. The Fund is also being hived off as a ‘dowry’ in a marriage of social and health service care.

See -
Liverpool Care Pathway - Transformation
So, what’s this...?

2.35pm Strong reaction across the board today in response to the safer staffing story, but also the news that the public health budget will be cut by £200m.
Louise Silverton, director for midwifery at the Royal College of Midwives, said: “This comes at a time when we should be investing more in preventative services and when there is an increasing and necessary focus on this from organisations such as NHS England; this seems to be a case of sheer folly. To also describe this as non-NHS spending is also very misleading.
10.55am The Department of Health is to consult on an in-year cut of £200m to council controlled public health budgets.
The proposal has prompted fears among NHS commissioners of a knock-on impact on their services.
The cut was revealed by chancellor George Osborne this afternoon, and was billed as a saving of £200m on “non-NHS” spending.
£200m hived off the Transformation Fund as a ‘dowry’ in a marriage of social and health service care.

£200m sliced off the Public Health budget.

We're seeing some very cute fiscal massaging and musical chairs here, are we or aren't we...?

A great cash and grab.

Or joined up services and seemingly seamless care?

An integrated NHS and the efficient use of finite resources.

Consistency, consistency, consistency

And it's all fall in with Even-Stevens Communitarian efficiency prioritisation as, addressing the NHS Confederation conference in Liverpool, he puts into suspension the Francis recommendations on safe staffing.

NICE moves to suspend work in response.

And David Behan’s CQC juggles quality and safety to fall in line, prioritising efficiency savings and “use of resources” in its ratings of NHS trusts as a “logical development” of its current approach.

Consistency, consistency, consistency...

Wednesday, 3 June 2015

Liverpool Care Pathway - A Dying Scandal

When it comes down to it, it’s much simpler, less bother and cheaper to just let them go...

It was a single and singular decision. The fact, de facto, could not be undone.

The domino tumbled.

This is ENCA 
PRETORIA - The Departments of Justice, Health and the NPA plan to challenge Judge Hans Fabricius’ decision to grant a terminally ill cancer patient the right to die.
Judge Fabricius last week gave advocate Robin Stransham-Ford the right to end his life with the help of a doctor. He said his decision related only to this particular case.
But the NPA and the health minister still believe it could open the floodgates on euthanasia.
They say the judgment not only contravenes the right to life entrenched in our constitution, but also compromises doctors' ethics.
“Doctors signed a Hippocratic oath which talks about life, life, and life. I won't give up to allow another arm of government to change the ethics and direction of doctors in the way that ruling is going to," said Minister of Health Aaron Motsoaledi.
Judge Fabricius is not prepared to withdraw his judgment.
“As I handed down the ruling on the 30th of April, the applicant had died that morning shortly after 8 apparently, I certainly didn't know that and nor did counsel. The result is that the application that I recall my order in terms of rule 42 is not granted," said Fabricius.
Dignity SA has its foot in the door...
The landmark case which presided in the North Gauteng High Court, was the first of assisted suicide in South Africa.

The case is a significant one as it could determine whether local doctors can in future assist terminally-ill patients to die.

The dominoes are tumbling...

Is South Africa to follow the same treacherous and uncertain path being followed by Canada?

Dr. Kenneth Stevens, an Oregon Professor Emeritus and former Chair of the Department of Radiation Oncology, Oregon Health & Sciences University in Portland, called Bill 52 a licence to kill.

CBC News
The non-partisan Bill 52, also known as an act respecting end-of-life care, passed Thursday afternoon in a free vote at the National Assembly in Quebec City.

Bill 52 allows for and outlines under which conditions terminally ill Quebecers can request to receive medical aid in dying.

Liberal Christine St-Pierre was one of the 22 who voted against Bill 52.

"I don't believe it's right to give [anyone] the power to kill somebody," St-Pierre said.
 Further reading -
In CNW Newswire, Dr. Stevens is named as a guest speaker at a conference of the Coalition of Physicians for Social Justice...
Dr Stevens will describe how hundreds of so-called "hopeless cases" with treatment can go on to survive many profitable years or be cured. He will explain how other people are encouraged to give up on care because of the existence of the assisted suicide law. The message of the proponents of assisted suicide is that "doctors can do a better job of killing you than caring for you."

Present at the conference and giving her testimony is a patient of Dr Stevens, Jeanette Hall. She was diagnosed in 2000 with lower bowel cancer and told that she had six months to a year to live. She asked for assisted suicide as provided by the state of Oregon. Dr Stevens disagreed with her decision for assisted suicide and was able to convince her to undergo radiation and chemotherapy. She is now thrilled to be alive 13 years after undergoing cancer therapy and not killing herself with a lethal dose of barbiturates.

Dr Stevens will discuss how financial incentives in Oregon's government health plan steers patients to assisted suicide. Dr. Stevens will warn that if assisted suicide or euthanasia is legalized in Quebec, then the Quebec government health program could follow a similar pattern limiting coverage for cancer care and thus encouraging euthanasia.

Dr. Paul Saba, a family physician and co-president of the Coalition of Physicians for Social Justice will explain how Québec's proposed euthanasia law would encourage people, including young adults 18 and over with treatable conditions such as depression, chronic lung and heart disease, diabetes, rheumatoid arthritis and fibromyalgia to agree to euthanasia and end their lives.
This already sounds like EoLC UK:

“Hopeless cases” diagnosed as dying and placed on EoLC Pathways;

The elderly and vulnerable signing away treatment intervention with an ACD and signing up to non-intervention with a DNR;

Lives cut short;

Others, escaping, removed from the Pathway, surviving months or years;

Financial incentive payments.

Baroness Greengross OBE, vice-chair of the All-Party Parliamentary Group on Choice at the End of Life, said:

Palliative care and assisted dying legislation share many common values: the alleviation of suffering, patient choice and a patient focused process. They should not be seen in isolation.
There you have it. The linkage is established. Euthanasia is but one step further along the Pathway, not at all the one step beyond it.

The culture is already cast without any legislation put in place to take life.

When it comes down to it, it’s much simpler, less bother and cheaper to just let them go...

And profitable if there is either de jure presumed consent or de facto written consent in place for organ donation to proceed.

This is Mail & Guardian 
On May 27 four Durban surgeons are due to stand trial for their part in South Africa’s kidney trafficking scandal.

But evidence in the Mail & Guardian‘s possession suggests that top Netcare executives are fortunate not to be standing beside them.

“Kidneygate” is the long-running saga of how—between about 2000 and 2003—about 200 Israeli patients with kidney disease were brought to South Africa to receive organs from living donors who were presented as their relatives.

The donors were in fact poor Brazilians, Israelis and Romanians who were recruited by international organ traffickers and paid a relatively modest sum to give up a precious kidney—a criminal offence under South African law.

To make matters worse, at least five of the donors are now known to have been legal minors at the time of the operations.

The four doctors—John Robbs, Ariff Haffejee, Neil Christopher and Mahadev Naidoo—are bitter at finding themselves at the short end of a chain of ethical dissimulation.

In theory, the buck stops with the doctor doing the cutting, but in reality, the transplant surgeons were little more than skilled mechanics dealing with bodies on an assembly line, maintained, paid for and legally underwritten by the big healthcare factory that is the Netcare Group.
Illegal organ donation by Notcare Netcare. What scope for legal profit is there?

Once the dominoes tumble...

In Oregon, Death prescriptions have increased by 500% in number from those written during the 1st year of Oregon’s assisted dying legislation -

Oregon Public Health Division
House Bill 3337 will spread the net of eligibility still wider.

Organ harvesting of euthanased patients is well organised, almost to a factory precision, across europe via Eurotransplant -

Notcare Netcare is a NHS provider -

NHS Choices
Once corporate suppliers - whether private or third sector - network with the State there is a scope for almost anything to proceed. It is the medical equivalent of the Military Industrial Complex.

This is NCBI  (National Center for Biotechnology Information) 

Initially, in the 1970s and 1980s, euthanasia and pas advocates in the Netherlands made the case that these acts would be limited to a small number of terminally ill patients experiencing intolerable suffering and that the practices would be considered last-resort options only. By 2002, euthanasia laws in neither Belgium nor the Netherlands limited euthanasia to persons with a terminal disease (recognizing that the concept of “terminal” is in itself open to interpretation and errors). 
In 30 years, the Netherlands has moved from euthanasia of people who are terminally ill, to euthanasia of those who are chronically ill; from euthanasia for physical illness, to euthanasia for mental illness; from euthanasia for mental illness, to euthanasia for psychological distress or mental suffering—and now to euthanasia simply if a person is over the age of 70 and “tired of living.” Dutch euthanasia protocols have also moved from conscious patients providing explicit consent, to unconscious patients unable to provide consent. Denying euthanasia or pas in the Netherlands is now considered a form of discrimination against people with chronic illness, whether the illness be physical or psychological, because those people will be forced to “suffer” longer than those who are terminally ill. Non-voluntary euthanasia is now being justified by appealing to the social duty of citizens and the ethical pillar of beneficence. In the Netherlands, euthanasia has moved from being a measure of last resort to being one of early intervention. Belgium has followed suit, and troubling evidence is emerging from Oregon specifically with respect to the protection of people with depression and the objectivity of the process.

The United Nations has found that the euthanasia law in the Netherlands is in violation of its Universal Declaration of Human Rights because of the risk it poses to the rights of safety and integrity for every person’s life. The UN has also expressed concern that the system may fail to detect and to prevent situations in which people could be subjected to undue pressure to access or to provide euthanasia and could circumvent the safeguards that are in place.
Once the dominoes tumble...

The net is being trawled. The moral guard has dropped.

A sea of debt averts the gaze. Cost ties the purse strings. Profit blinds moral restraint. Whither are we bound?

The Pathway is treatment and death is therapy...
"Last month the chairman of the Royal College of General Practitioners expressed himself "horrified" by the discovery that many of the 114 British "clients" of Dignitas had not been suffering from terminal illnesses at all."
(Dominic Lawson: Death, dignity and the darker side of family dynamics - The Independent)
Would the chairman of the Royal College of General Practitioners express himself equally "horrified" by the discovery that many of those placed on the Liverpool Care Pathway had not been suffering from terminal illnesses at all?

The linkage is established. Euthanasia is but one step further along the Pathway, not at all the one step beyond it. The culling of the vulnerable, the elderly, those assessed living a life not worthy of living further establishes this link.

The net has been cast wide in all directions to permit more and more and to remove all restraint.

It is now more than eight years the net was cast to trawl in the incurably mentally ill. This is Medscape 
Now, a recent decision by the Swiss Federal Supreme Court threatens to undermine yet another longstanding taboo in the debate over assisted suicide and euthanasia. In its ruling on November 3, 2006, the high tribunal in Lausanne laid out guidelines under which, for the first time, assisted suicide will be available to psychiatric patients and others with mental illness.
The case was that of an unnamed fifty-three-year-old manic depressive with two prior suicide attempts who sought a prescription for fifteen grams of sodium pentobarbital in order to end his own life.He claimed a right to self-determination under Article 8 of the European Convention on Human Rights and alleged that no physician would prescribe him this lethal dose for fear of legal or professional repercussions. Dignitas, a Zurich-based advocacy group, supported his suit. The Swiss high court responded with a sweeping opinion upholding the right of those suffering from "incurable, permanent, severe psychological disorders" to terminate their own lives.
It has been a circuitous route but are we already on the pathway back to T4?

Depression used to be cited as a reason why the desperate might seek suicide.

Is depression also a reason to seek suicide...?

This is all very messy.

Where does this leave those who seek to step in and lead the suicide back from the brink?

Do they, in doing so, infringe upon the suicide's human rights?

A messy Assisted Suicide Bill is to go before the Scottish Parliament -

The Pathways have EoLC Facilitators. This messy bill has licensed Suicide Facilitators...
The role of the licensed facilitator

Support for the role of ‘licensed facilitator’

232. The creation of the role of ‘licensed facilitator’ has been widely welcomed by supporters of the Bill. It has been described in written submissions from supporter organisations as  “a welcome measure”, “a large step forward” and  “one of the main merits of the Bill”. Supporters point to several potential advantages.

233. First, the role of facilitator places a degree of distance between medical professionals and the direct act of assistance; this may be necessary given the reported reluctance among members of the healthcare professions to be involved in facilitating assisted suicide (discussed above); in the words of Rob Jonquière of the World Federation of Right to Die Societies, it "takes away a burden from the shoulders of the treating physician".

234. Second, the role of licensed facilitator is described by several supporters‘organisations as a "safeguard" for the person committing suicide. In their written submission, for example, Friends at the End suggest that the facilitator role  “offers additional protection for the vulnerable”.

235. References to the role as a ―safeguard‖ seem to refer to two things: first, the fact that assistance would be provided by a trained individual, thus allowing for “a safe and careful execution of the (assisted) suicide”; and second, the fact that the assister would have no personal connection to the person being assisted, unlike friends and family members who may feel motivated to try to interfere with the autonomous decision of the individual (either by encouraging someone to commit suicide or by attempting to dissuade them from doing so).
There is to be a “safe and careful execution of the (assisted) suicide”. Is this not, already, an unfortunate choice of words?

The Facilitator is an Executioner.

And this in this Saturday's Daily Mail -

Dignitas is sending people who want to die to a banned British doctor for approval they need for an assisted suicide, the Mail can reveal.

The clinic is telling patients to get a report from a controversial psychiatrist struck off nine years ago for serious misconduct. They say that Colin Brewer – who has helped at least 12 patients to die at Dignitas – is prepared to support cases even where the patient is not terminally ill.

Brewer has previously spoken openly about how he helps people without terminal illnesses to die. He co-edited a book, I’ll See Myself Out, Thank You, which horrified opponents of assisted suicide. In it he detailed the cases of seven patients he has written assessments for, who went on to die at Dignitas. Only one had a terminal illness. Speaking about Jacques, a retired academic in his seventies who suffered arthritis, heart disease and high blood pressure, Dr Brewer said: ‘It sounds no worse than in most people of his age. But he dreaded the possibility of a sudden deterioration… that would deprive him of the mental capacity to decide on the manner of his death.’

Brewer says a third of the patients who contact him are referred by Dignitas. Others find him from campaign groups such as Friends At The End, who yesterday said they were ‘proud’ to recommend him.
Brewer's victims find their way to him via Friends at the End who are "proud to recommend him."

Friends at the End back the role of the Executioner as a "safeguard".

Perhaps, Brewer should consider applying for the job when it comes up.

And legal killing is not yet even legal in this land.

With the final word, this is Eric Chevlen in The Sacramento Bee 

People with terminal illnesses do not seek suicide, assisted or otherwise, because of pain. Patients in pain seek pain control, not death. Fortunately, modern medicine can reduce pain to ordinary levels that we all have experienced. The terminally ill do not seek suicide, assisted or otherwise, because of the burden of treatment. Patients who find treatment burdensome rightly have the option of simply discontinuing treatment.

Rather, without exception, those patients who have asked me to hasten their death did so out of despair. They despaired of having lives of value, of being the object of the loving care of others. They mistook being dependent for being a burden, or mistook being a burden for being contemptible. They were sick and weak, and mistook uselessness for worthlessness. Despair is indeed the sickness unto death.

A doctor whose response to a request for assisted suicide is a scribbled prescription for a lethal drug does his patient the terrible disservice of abandonment. It is a tacit admission that the doctor agrees that the patient’s life is of no value. It is hard to imagine a more contemptuous act.
And some final reading –
Liverpool Care Pathway - Presumptuous And Arrogant 
Liverpool Care Pathway - So Readily Do Perceptions Change... 
Liverpool Care Pathway - There Are Always Consequences 
Liverpool Care Pathway - The Sum Of All Fears