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

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