Sunday, 27 April 2014

Liverpool Care Pathway - The Dangling Conversation...

Studies have demonstrated death to be a key focus of the day to day business of hospitals...

The dangling conversation...
Yes, we speak of things that matter
With words that must be said:
"Can analysis be worthwhile?"
"Is the theater really dead?"
- Paul Simon
And do we speak in homonyms...?
The phone rings. It is 2am. It is a young voice, the voice of a man. He confirms who I am.
“We need to talk about resuscitation...”
He is talking about my brother...
“If anything happens, we’ll be jumping on him and all sorts of things; it wouldn’t be very nice.”
“As a medical person, you always do everything you can...”
“You want us to use CPR?”
The conversation peters out.
Jane Ellison responded to Mr Nicholas Brown at Question Time that permission is not required to slap a DNR on a patient’s file...
This is Hansard –
A decision not to attempt cardiopulmonary resuscitation (CPR), like other decisions not to attempt a particular form of medical treatment, does not require the patient's consent. However, as with all clinical decisions, healthcare staff are expected to be able to explain and defend their decisions to their employing authorities and their professional regulatory bodies.
They do not require our permission but they may want it.
The phone rings half-way through another busy working morning. It is a young voice, the voice of a woman. She confirms who I am.
“We need to talk about resuscitation...”
She is talking about my brother...
“Can you come in today to speak to the registrar? It is important you have a discussion about resuscitation.”
“It is important we have a discussion about the infection J*** has picked up.”
There is a space of silence.
In 2011/12, of the more than 32,000 discharges from Ontario’s long-term care facilities, almost half left in body bags. This is Palliative Care: Research and Treatment from Libertas Academia –

The average age of LTC residents in this study was 84.5 years, and about 70% were female residents. Results showed that residents admitted from home were less likely to have a DNR order on file during assessment and three months later. Residents whose families were responsible for care were more likely to have DNR orders when admitted, but this effect was not found at three-month follow-up.

When family members are responsible for care, it appears that a DNR order is more likely to be in place. What may we infer or construe from this...? This has implication and consequence.
The factors that influence whether residents have DNR orders on file upon admission depend on the presence of family members, whether the residents are designated as end-of-life cases (six months or less), older age, and health. Discussions about resuscitation are an important part of care plans.
Silence is a space, vacant, waiting to be filled...
“This is a hospital-acquired infection...”
Another space intervenes.
“J*** is in a side room. I have been told he’s been vomiting. I am required to don gloves and apron to go in the room. Have the results come back...?”
“If you  will come in...”
“When is J*** going back to the nursing home? The sooner he’s removed from the source of infection, the better.”
“My registrar has asked me to talk to you about resuscitation.”
“You just want to slap a DNR in J***’s file. I need to discuss how J*** has contracted this infection.”
There is another pause. “I don’t know...”
Thankfully, there is inconsistency in their stance and in their attitude to CPR and DNR orders. This is a clear indicator that the arrogant Death Cult which struts brashly through hospital ward, into care home and surgery consulting room, audacious, presumptuous and insolent, has not yet won the day. We are still only halfway there.

This is the Liverpool Echo –
A Liverpool nurse who failed to perform CPR on a nursing home resident who later died will have to be supervised while he works  for the next 12 months.
Joseph Imathiu was brought before the Nursing and Midwifery Council accused of misconduct over the incident which happened at Wavertree Nursing Home in March 2012.
Imathiu told the panel he was unable to complete CPR (cardiopulmonary resuscitation)  while he was on the bed as the bed was “sagging” and a hard surface was needed.
The hearing was told Imathiu asked two healthcare assistants (HCAs) to place him on the floor and as they were doing so left the room to call for an ambulance.
Imathiu told the panel he had intended to perform CPR when he came back but almost immediately after he had returned to the room the paramedics had arrived and were doing CPR.
Imathiu said one of the HCAs could not have called for the ambulance as they were “inexperienced”. After the paramedics had performed CPR unsuccessfully for 25 minutes the elderly man was pronounced dead.
Imathu, a nurse with 30 years experience under his belt, only had to present the ‘Lakhani Defence’ as just cause not to perform CPR.

In performing CPR, success is slim; Imathu was permitting this elderly gentleman “a naturally dignified death because he was a dignified person”. This is the 'Lakhani Defence'. Imathu was only following the Lakhani Recommendations.

And, clearly, the Nursing Home was being remiss in not putting Care Plans in place. Discussions about resuscitation are an important part of care plans.

The conversation dangled...
“You do know J**** has an infection?
“Then, I need to speak to someone who does know. You’re a member of your registrar’s team and you don’t know?”
“We need to discuss resuscitation. Will you be in today to speak to the registrar?”
“Yes, I’ll be in. Will you be there?”
“I may be...”
I am on the ward. There is no-one about. Outside the side room, I am ready to don apron and gloves. I look through the open door.There is an elderly patient in the room in J***’s place. She does not look up; she is preoccupied about some matter. I am becoming concerned.
I look in the next room. No, not there, either...
Here, Katie Morales raises some serious ethical issues in an article which discusses the Lazarus Phenomenon. This is...
the delayed return of spontaneous circulation (ROSC) after cessation of cardiopulmonary resuscitation (CPR). In other words, coming back to life after being pronounced dead. And it can be the root of an ethical issue in nursing.
Walter Williams, an elderly Mississippi man “died” at his home. His hospice nurse called the coroner, who arrived and declared him dead.

At the funeral home, as workers were preparing to embalm him, he started to move. The very next day he was well enough to talk with his family.

This was in February of this year. Mr. Williams subsequently died in mid-March.

Katie Morales writes in Nurse Together -
The Mississippi man was a hospice patient. Many hospice patients are DNRs (do not resuscitate). This brings another curious wrinkle, a potential ethical issue in nursing. Was it even appropriate for the funeral home to call an ambulance?
Although not common, healthcare workers have been sued for wrongful life after successfully resuscitating patients with DNR orders in place. In 2011, a Colorado inmate sued the prison for performing life-saving measures. In 2013, a Florida woman sued a hospital and nursing home after medics successfully revived her mother despite a do not resuscitate order.
Another consideration is if patients with DNRs have implanted pacemakers/defibrillators in them, such as the Mississippi man. The device will fire when appropriate, despite physicians’ orders or patient’s wishes to the contrary.
In the case of the Mississippi man, if he had been without a pulse or oxygen for this period of time, he surely would have suffered brain damage. However, reports state that he was awake and talking.
Mr. Williams had been fitted with an internal defibrillator (ICD). This, of itself, raises ethical questions in the matter of withdrawing or denying treatment.

At Mid Cheshire, they have replaced their PIG (Prognostic Indicator Guide) with the EPAIGE (Electronic Prognostic Assessment & Information Guide for End of life care). Wee Bee Long and her dying people alliance might well learn a thing or three from these people. Great strides have been made since the days of the Barton Method aka The Surprise Question.

Modern ICDs act as pacemakers and defibrillators. Here is discussed deactivation of ICDs with the use of a magnet... 

If you require deactivation of an ICD urgently outside office hours, a magnet is available from Macclesfield CCU. This can be strapped to the chest using adhesive tape over the implant site.
 Further reading -
Liverpool Care Pathway - Catch Up EoLC

 Nurse Together continues -
Also, despite having an internal defibrillator, it is unlikely he went from an unshockable rhythm (asystole) to a shockable rhythm (ventricular tachycardia or ventricular fibrillation). This begs the following questions: 
  • Was this man ever really without a pulse and not breathing?
  • How did the hospice nurse determine the man was dead?
  • Did the nurse auscultate heart sounds or merely feel for a peripheral pulse?
At Mid Cheshire, thankfully, they can recognise when a patient is in the last days and hours of life. Otherwise disablement or deactivation of an Implantable cardioverter defibrillator (ICD) might be a death sentence.
I’m back at the nurses’ station. There is a lone nurse at the desk. “Can you tell me where J*** is please? He was in that room just there.” I indicate in the direction of the room.
She pauses, rifles through some documents. A puzzled look adorns her face.
“I think he is gone...”
Another nurse returns to the station from some duty which had kept her.
The first nurse looks up from her ponderings. “Do you know where J*** is?”
The second nurse muses. “J*** is gone I think.”
Neither nurse is certain. There appears no paperwork to paper chase J***’s whereabouts.
I am perplexed. “He’s gone back to the nursing home...? I spoke to a doctor on the phone just this morning.”
A face peeps out through a door. It is a young, fresh-faced man in a check shirt, seated in a chair. “I think he’s gone to G**** Ward, just next door.”
He acknowledges our confusion and beams with pleasure he is able to assist. “Yes, I wondered where he’d gone myself...”
Katie Morales writes -
Peripheral pulses can be hard to palpate in critical patients. As a Georgia nurse, I cannot legally pronounce patients dead. I can determine there is no pulse and respirations.
To accurately pronounce a patient dead, however, one must examine the patient. Following standard emergency assessment protocols, gently call the patient’s name as you rub the patient’s face or chest to determine unresponsiveness by trying to arouse the patient. Next, look, listen, and feel for the presence of a pulse and respirations. Auscultate heart sounds and palpate for a carotid pulse and check for pupillary light reflex.
The absence of all of these indicates the patient is dead. The time of the exam is noted as the time of death.
I have to believe these cases are rare. For it to be otherwise is simply unthinkable and reminiscent of a Robin Cook novel. We must never forget how fragile life is as we tend those entrusted to our care.
Life is fragile and life is precious.
“I understand J**** has been moved here from B***** Ward...?” I am on G***** Ward speaking to a nurse at her station. She directs me to Room 3.
J**** is in a larger room with none of the prior restrictions on entry. He is on a sodium lactate (Hartmann’s Solution) drip and oxygen. I notice he has a fluid restriction of 1500ml. There is no monitor, however. There is no-one about to ask about the infection.
A nurse appears outside with a dispensing trolley. She looks at the chart and obliges my request for information by telling me that J**** is still on antibiotics. These will continue for a few days. They will look for markers to see if these are taking effect. She knows nothing  of the phone call today.
Katie Morales concludes her article with a question: Do nurses have the right to pronounce a patient dead?

May doctors, likewise, pronounce a patient to be dying and then act upon that decision by withdrawing or withholding treatment that makes that end that more certain?

Sunday, 20 April 2014

Liverpool Care Pathway - Appointment With Death

This is the ultimate death plan. It may also be a consideration for diligent actuaries to factor into their calculations.

This is the Express & Star –

As part of Government guidance intended to help pensioners plan how much to spend and save, pensions minister Steve Webb said experts could look at factors such as smoking, eating habits and socio-economic background when determining approximate life expectancy.
He said giving people an idea of how long they might live would help them make informed financial decisions.
The Coalition plans a pension overhaul next year to save money. As part of these reforms, Steve proposes that retirees be given a guestimation of when they are likely to die; quite literally, a date to plan for and a date to die for. This is the ultimate Death Plan.

Talk is he'll also supply info about Dying Matters and the local Death Café.

Upon what scientific data will this latterday Senna base this date with the Grim Reaper? Likely, he'll refer to figures supplied by the ONS (Office of National Statistics) and base his grim forecast on these. This is, quite literally, an appointment with death.
“Woe, woe and thrice woe...!"
- Up Pompeii
This is Agatha Christie's "Appointment with Death"...
The words are uttered by unseen lips: ‘You do see, don’t you, that she’s got to be killed?’
How apt: the elderly Mrs Boynton is put down with a hypodermic syringe. This is her appointment with death. This is Poirot.

Mr. Patrick Gordon Walker’s landmark observations whistle down the wind and yell from the rooftops.

You do see, don't you, that we've all got to be killed...?

Which figures, in particular, will Steve use? The stats say, he says, we're all living longer and that's why we need to plan out our pension pots and not blow them on a Lamborghini.Yes, he actually said that, apparently.

He might be more concerned we save up for EoLC. Already, this year, hard-pressed home-owners have unlocked £315million of equity. This is a fancy name for debt. This does not bode well.

This is the End of Life Baseline Report –
End of life care is a key priority of the North West regional QIPP workstream for Demand and Threshold Management and the North West SHA in recognition that improving QIPP across the end of life care pathway will significantly support overall delivery against the £20 billion QIPP challenge by 2014/15. 
The North West vision is for people to be supported to die well in the place of their choice; with a broad aim to reduce avoidable hospital admissions for patients at the end of life and to expedite discharge for end of life care patients who are admitted to hospital for emergency care.

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”.
The Baseline Report was published in 2011. They are concerned about a "Tsunami of need". That's extravagant and alarming language...

But the projections are not marrying up. There are 'excess deaths'. There are 'missing' 90 year-olds. The EoLC Strategy has taken its toll.

The stats show that the gender gap for life expectancy has closed from 6 to 4 years. Rather than a positive outcome, reflecting better lifestyle choices for instance, this may actually be another indication of the effectiveness of the EoLC Programme.

This is MSN –
Retirees risk being misled by estimates proposed by ministers which would tell them when they are expected to die unless this information is regularly reviewed, a leading pensions expert has warned.
Pensions Minister Steve Webb has suggested that giving people who are nearing retirement an idea of how long they might live for would help them make informed financial decisions.
But Ros Altmann, an independent pensions expert and a former Downing Street adviser, said the information could be "not terribly helpful" and "a bit misleading" unless the figures are regularly revised over the course of someone's retirement to take account of any life changes and backed up by detailed guidance.
She said: "Unless you've got some process where you update the figure it becomes a bit meaningless.
Sounds like Ros considers this yet another ‘pathway’ upon which to consign us without proper intervention by review.

This is Dr. Philip Howard speaking on the The Big Questions –
One of the problems about the Liverpool Care Pathway is that a decision is made and then, very often, observations are stopped, nursing observations are stopped, simple blood tests are stopped and further interventions are usually stopped – with the exception of oxygen, interestingly enough; that’s continued in 45% of cases. But most other interventions are stopped and very rarely started. When… How can the patient be properly reviewed if you don’t have basic nurse observations, basic blood tests and so on? After three days, em… three quarters of the patients have died, but of those that are still alive, according to the audit that was done of 7,000 patients two years ago, only 20% were reassessed.
More tools to determine your date with death.

Who knows, perhaps an appropriate banding system could be applied and those suitably classified might be brought to the attention of the local pro-euthanasia/Age UK assertive outreach team and targeted  for PCTs and ACPs. This could be a 'Great Leap Forward'; after all, we are only 'half way there'...

Pertinent reading –
Liverpool Care Pathway - Crossing The Rubicon
What other resources are available to Steve?

Steve could dip into the vast treasure chest of personal health info held on the SCRs by

There are tests that have been developed using statistical modelling based on years of research into diseases.

One widely used method is called the Framingham Risk Score. This is used to estimate a person’s risk of developing cardiovascular disease or events, such as a heart attack, in the following 10 years. This is based on looking at individual risk factors such as age, smoking history, cholesterol levels and blood pressure.

Even so, these are only probabilities of risk and deal in generalities. The 'one size fits all' hypothesis really does not apply and these are but stars to steer by, not pathways to follow.

The London Knowledge and Intelligence Team at Public Health England have developed the Segment Tool.

A ‘to die for’ tool is reported by the Institute for molecular Medicine Finland.

This is Fimm –
A new screening technology reveals a signature of mortality in blood samples.Researchers have identified four biomarkers that help to identify people at high risk of dying from any disease within the next five years.
The identified biomarkers were albumin, alpha-1-acid glycoprotein, citrate and the size of very-low-density lipoprotein particles. Of these, albumin was the only one previously linked with mortality. All these molecules are normally present in everyone's blood, but it is the amount of these molecules that was shown to be important.
The novel biomarkers helped to detect individuals at much higher risk of dying during the five-year follow-up. The measures were independent of well-known risk factors such as age, smoking, drinking, obesity, blood pressure and cholesterol. The result did not change even when only apparently healthy persons were examined.

Could this be incorporated into GSF and SPICT to give them a more scientific grounding? Do we hear a rumble of excitement stirring amongst the Wee Bee Long Alliance...?

Wee Bee Long has developed her own prognostic tool. Read more here -
Liverpool Care Pathway - The Bee Wee Tool
And there are other tools coming online for Steve to consider. There’s a ‘to die for’ thingamy gadget tool worn like a wristwatch. Read more at...

Liverpool Care Pathway - The To-Die-For Tool
Is this ultimate death plan the ultimate plan?

The pieces of the jigsaw are come together. The Complete Lives system is our pathway trajectory. We are given our appointment with death. Or we choose our own. The new euthanasia laws are installed to accomplish that death.
We have no control over how we arrive in theworld, but at the end of life we should have legal control over how we leave it.
- Patrick Stewart
Absurd? Our culture has changed, is changing, before our very eyes. It is only a matter of appropriate grooming and the development of suitable psychometric tools and what was the unacceptable will become, is becoming, the acceptable and the norm. Once the goal posts are moved, the precedent is set.

Organ harvesting is already become the norm where permission is already a legal assumption and this supplies additional new logic and purpose.

Already, in a land far off, from where hails the Wizard of Death, in the Land of Oz down under, we have seen this via the autonomous action of one individual. Beverley Broadbent felt the years catching up on her...

Absolutely essential reading –
Liverpool Care Pathway - And "Rational" Suicide
Further reading –
Liverpool Care Pathway - Recruiting And 'Transforming'!
Liverpool Care Pathway – "Let's Talk About It..."
Liverpool Care Pathway - Nothing Changes But It Stays The Same
The corrupt pro-death advocacy is in power. It uses public funds to further its aims and objectives. It uses lottery funds to this end, also, obtained fraudulently...

The State picks our back pockets whilst the Third Sector sends its chuggers out onto the streets to cajole us and to badger us into signing up to have our bank accounts tapped to fund their endeavours.

A triumvirate of State, Third and Private Sector rules. The State outsources the NHS to the Third Sector. The Third Sector forms mutually advantageous partnerships with the Private Sector. This is an emerging Corporatism. Corporatism is Fascism. There is a Fascist Regime in the making.

A seismic shift is in place. We are 'half way there'.

‘Transitions to palliative care for older people in acute hospitals: a mixed-methods study’ is a research document funded by the NHS National Institute for Health Research -
Improving the provision of palliative and end-of-life care is a priority for the NHS. Ensuring an appropriately managed ‘transition’ to a palliative approach for care when patients are likely to be entering the last year of life is central to current policy. Acute hospitals represent a significant site of palliative care delivery and specific guidance has been published regarding the management of palliative care transitions within this setting.

A mixed-methods study was conducted in two hospitals serving diverse patient populations: Sheffield Northern General Hospital and the Royal Lancaster Infirmary.

Of the 514 patients in the inpatient survey sample, just over one-third (n= 185, 36.0%) met one or more of the Gold Standards Framework (GSF) prognostic indicator criteria for palliative care needs. The most common GSF prognostic indicator was frailty, with almost one-third of patients (27%) meeting this criteria. Agreement between medical and nursing staff and the GSF with respect to identifying patients with palliative care needs was poor.

The study concerns the successful identification of patients to be classified as palliative. This has been a long focus of the EoLC programme to downsize care expectations. There is a dual aspect to this.

One: The potential annual cost saving across both hospitals of preventing these admissions is approximately £5.3M.

Two: A 2- or 3-day reduction in length of stay for these admissions would result in an annual cost saving of £21.6M or £32.4M respectively.

The study concludes:
Patients with palliative care needs represent a significant proportion of the hospital inpatient population. There is a significant gap between NHS policy regarding palliative and end-of-life care management in acute hospitals in England and current practice.
The study is funded by NIHR. The National Institute for Health Research (NIHR) is a member organisation of Wee Bee Long's Leadership Alliance for the Care of Dying People and conducts clinical research on NHS patients.

Of the 514 patients in the sample, just over one-third met one or more of the Gold Standards Framework (GSF) prognostic indicator criteria for palliative care need.

The most common GSF prognostic indicator was frailty, with almost one-third of patients (27%) meeting this criterion.

Once upon a time, it was accepted that frailty was an inevitable condition of old age and this would be responded to with more care, not as an indicator for less.
The retrospective case note review identified that 255 out of 483 patients (52.8%) who had died following an admission to hospital showed some evidence of a transition to a palliative care approach before death (do not attempt resuscitation order 47.4%, placed on Liverpool Care Pathway 14.1%, referral to specialist palliative care 9.1%, prescription of long-term opiates 9.9%, use of syringe driver 3.3%, advanced decision to refuse treatment 0.8%).
Over half the patients who died following admission (52.8%) were being flagged for palliative care.
The significant predictors of a transition to palliative care were the GSF indicators for cancer, heart disease and stroke, together with age and living in a residential or nursing care home.

Of the 183 patients who met GSF criteria for palliative care need and for whom complete data were available, 61 (33.3%) showed evidence of a transition to a palliative care approach by meeting one or more indicator of adoption of a palliative care approach [do not attempt resuscitation order (29%), referral to specialist palliative care (8.2%), prescription of long-term opiates/syringe driver (4.9%), on Liverpool Care Pathway (1.1%), documented advance care plan (0%)].

Older age was perceived by health professionals to act as a barrier to accessing specialist palliative care because older people were seen to have less need for specialist input as a consequence of death being more expected and the perception that older people find it easier to come to terms with a terminal diagnosis.
A third of patients (33.3%) flagged up by the GSF were followed through with palliative care. 'Older age' is a barrier for treatment. Perversely, the study shows that this barrier extends through to palliative treatment.

The study concludes:
Patients with palliative care needs represent a significant proportion of the hospital inpatient population. There is a significant gap between NHS policy regarding palliative and end-of-life care management in acute hospitals in England and current practice.
Clearly, the study considers that more needs to be done in the acute hospital setting to identify EoL patients and to close the perceived gap.

Already, so many patients are being identified as palliative that it has rung alarm bells with  independent auditors that the figures are being massaged to conceal wrongdoing or malpractice.

This is the End of life studies blog at the University of Glasgow –

Our census identified 10,743 inpatients in 25 Scottish teaching and general hospitals on 31 March 2010 (we excluded cottage and community hospitals and long stay facilities).  We found that 3,098 (28.8%) patients died during the one year follow up period: 2.9% by 7 days, 8.9% by 30 days, 16.0% by 3 months, 21.2% by 6 months, 25.5% by 9 months and 28.8% by 12 months.
The likelihood of dying rose steeply with age and was three times higher at one year for patients aged 85 and over, compared to those who were under 60.  Men were more likely to die than women.
A striking finding was that almost one in ten patients (9.3%) of patients died during the  admission on which we recorded them – and this accounted for 32.3% of all the deaths within the 12 month follow-up period.

The article, “Imminence of death among hospital inpatients: Prevalent cohort study”, is published online on March 17, 2014 in Palliative Medicine by Sage Journals –

As with the previous study funded by NIHR, a "mismatch between current best practice recommendations on transitions to palliative care in acute hospitals and the observed clinical reality" is highlighted. The article cites the National EoLC Programme and the Route to Success documents. Read further here -
Liverpool Care Pathway - The Palliative Option And Downsizing Care

The article is based on data obtained from 25 Scottish teaching and general hospitals in 2010. The study concludes:

We have shown in the Scottish context that almost 1 in 10 patients in teaching or general hospitals at any given time will die during that admission. Almost 1 in 3 patients will have died a year later, rising to nearly 1 in 2 for the oldest groups
Both studies demonstrate death to be a key focus of the day to day business of hospitals north and south of the border. The statistics originate from a period at the height of the EoLC Strategy, as do the statistics used by the independent auditor now ringing the alarm bells.

The Doc Foster graph fits well with the statistics from the two studies and coincides with the EoLC Strategy and the reported “Excess Deaths”.

Cure and rehabilitation are no longer key options. In our own unhappy and distressing experience, 'rehab' turned into a shameful lie.

In 1941, the eugenicist, social architect and, latterly, Liberal MP, William Beveridge, was appointed to chair the committee set up by Arthur Greenwood which would call for a "cradle to grave" National Health Service.

Beveridge was one of those 'advanced' thinkers, prominent with the Fabians in the LSE.

The post-war years saw a surfeit of 'advanced' thinkers in every field, redefining social values and what they perceived to be antiquated, 'Victorian' thinking.

Beveridge favoured central planning.

Today, we have birth by induction and, via the EoLC Strategy and EoL Programmes and death lists and death pathways, death by induction. How better to complete this than by institution of the Communitarian Complete Lives system and the ultimate death plan with a pre-arranged appointment with death executed via the euthanasia bill set to go through parliament?

The 1946 film 'Land of Promise' calls for the wartime spirit to carry on into peace time. It makes a rousing piece of rhetoric.

Full transcript of the film "Land of Promise, The Will to Win"
Three men in suits and ties stand looking straight into the camera. They are in a pub and one of them in standing behind the bar; there are shelves of glasses in the background.
Narrator: "Come on then, come on, get cracking. It's not enough to end one war, we've got to end them all. You think we've finished with the aggressor? We haven't."
The men react one of them puts his head in his hand. 
An older man with a cap and coat on stands outside, an elderly woman and a young boy sit in a doorway, a crowd of people mixture of ages. 
"He's trampling the dim streets under his jack boots yet. They're waiting for us down there in those occupied territories. They're waiting for D-day and the armies of liberation. Come on then you leaders; come on, where are you?" 
A man climbs a ladder onto the roof of a house in the process of being built, a doctor at his desk with a patient standing in the background, several planners looking at maps, social worker sitting at a desk talking to somebody who is sitting opposite him, large group of people walking down the street, somebody looking through a microscope, group of young women, an elderly lady, large group of men some smoking. 
"Architects, doctors, planners, engineers, social workers step out into the light. It's you who have to plan this invasion. We are waiting for the signal now. A thousand years we've been waiting come on then, come on, let's hear it." 
Narrators voice goes quieter
Screen goes black and you see the shadow of a man walking out from behind the camera. He comes to stand in the middle of the 3 men at the beginning of the clip and is the narrator. He now talks directly to the camera. The three men stand watching and listening to him. 
"So you're still afraid some of you, hey? It's hopeless; it'll never be done. You can't change human nature, and so on and so on and so on. Well you think again. If somebody came along to you and said: 'Listen you British, give it up. Chuck it you feeble democracy and admit you're beaten.' Well what would you say to that? How would you take that? Lying down? Not much! Well then, what are you afraid of now? The only real wealth of a country is the health and happiness and freedom of its people. Who dares to estimate the money value of children killed by poor food and bad housing? Who dares to put a price on the million people killed by bad housing between the two Wars? The old fashioned way of reckoning human well-being in terms of profits. I tell you that way of thinking has got to be eliminated, liquidated, mopped up, wiped out!" 
Many people stand together all dressed in overalls and working clothes, a pilot, soldier, factory worker, a woman working in a laboratory, miner and a farmer in the fields, a man with hat, tie and jacket, back to the group of working people, shows an aeroplane in the middle of crowd. 
"Look round you. There they are, the men and woman who beat fascism; the men and woman in the fighting services; the merchant seamen; the workers in the factories and laboratories; the mines and the fields. You know who you are? You, yourselves, millions of us, there's our army there where it always was, standing upright in the shoes of the common people and who's the enemy?" 
View over a town with a large chimney, back to a closer scene showing the narrator with the 3 men standing very close to him listening and looking concerned. The narrator talks directly to the camera and gestures with his hand, the volume of his voice starts to increase. 
"The dictator who rules by force and not by reason; him and his collaborators. Now then, I'll give you your answer to problem number three, it's in your hands right now. Yours by the constitution of this country all the ministries of this and that; they are the servants of parliament. All the MPs from the towns, cities and countryside: they are put there by us to represent us, tell them, you have the right, that's real democracy, that's what we've been fighting for." 
View over a town several roofs of houses with smoke above them and mountains in the background, large crowd of people. 
"Are you going to use your right? Or will you shut your eyes and let yourselves and us be lead into one crisis after another. Into worse depression, worse poverty, worse slumps, worse sickness. Come on make up your minds. If you lose this chance it may never come again. There are millions of us, you and me: we are the British people. no power on earth can stop us once we've the will to win."
Those who have placed themselves above the law we have torn down and they have paid for their hubris. And those who place themselves above and beyond the law; how shall we deal with them when the time comes? Shall we mete them also the harsh justice they deserve?

How have they got away with it? How do they continue to get away with it?

They are many and powerful and are paid out of public funds to do their worst by us. We struggle, using our spare time to discover the truth. It is by our honesty and determination, which will serve us well and see us through, that we shall somehow see this through and bring them finally to heel.

Mr. Ellershaw, Dr Coackley, I will say just two words. These two words are a name. That name is Jack Jones.

Shall that name be our rallying cry? There have been so many...