Tuesday, 3 February 2015

Liverpool Care Pathway - Of CQuINs, Tipping Points And QUELCAs

A "silver-haired tsunami of need", a "time bomb"...
Is this how we describe those we should cherish and look up to?

They were talking about this fifty years ago. This was discussed in his landmark speech by Patrick Gordon Walker. See –
Liverpool Care Pathway - The Werther Defectives
Liverpool Care Pathway - When The Caring Had To Stop
They were still talking about this one year ago at the Time Bomb Conference in Hartlepool -
- Care Industry News
The major focal point of the day is to address the End of Life Care Pathways that change this year following the phasing out of the Liverpool Care Pathway
Discussion, which also provided a Syringe Pump Tutorial, proceeded on the implementation of EoLC Pathways.

These are our old ones, described variously as a 'tsunami of need' and a 'time bomb'. These are not terms to use to inspire feelings of concern and care but stirrings of emotion to act on an urgent need which must be dealt with and done away with as efficiently and expeditiously as possible.
The doctor flagged up for admission...
See -
Liverpool Care Pathway - Still Playing Games Of Consequences
No more...
This is Pulse -
The ‘Bolton Quality Contract’ will see practices’ core funding brought up to £95 in return for meeting a number of ‘quality standards’, including practices agreeing to a transfer of work into general practice where this is ‘clinically appropriate’ and working proactively to anticipate and prevent emergency admissions
It was by using the CQuIN payments system that the DoH expanded the LKP death pathway programme throughout the NHS and beyond. A CQuIN supplement is now to be paid to GPs by Bolton CCG to bring many services in-house and to flag down emergency admissions.
It has long been realised that attitudes to traditional first attendance would have to change.

Results NHS band and educational background are the main influences on the participants views of End of Life provision provided by paramedics. Length of service as a paramedic and experience appear to be factors that affect confidence when dealing with these incidents in practice. The majority of participants rated that communication about End of Life Care between services is poor. Most participants would like EOL training to be mandatory and would prefer face to face training to self-directed learning packages.
Conclusions Communication between services is viewed as poor whilst staff backgrounds influences their views. Whilst the majority of paramedics feel that End of Life Care it is a key part of their role, there is a need for wider training to address differences in staff awareness, knowledge and confidence.
And this is succeeding, as is evidenced by what has been described as a ‘secret policy’ at East of England but which, in point of fact, is a programme.

Hospitals have been demonstrated not to be safe. It was reported as such two years ago. The frail and the fragile, the vulnerable and the elderly, are to be treated in the community for their own protection...
Liverpool Care Pathway - This Is Not 'Ageism'; It Is Communitarianism
Liverpool Care Pathway - Going Stateside 
Cambridge News has reported that there is a 'tipping point' -
Researchers have identified the point at which busy hospitals begin to fail, resulting in deaths of critically ill patients.
Stefan Scholtes, professor of health management at Cambridge Judge Business School, along with German colleagues, investigated bed occupancy levels and death tolls in 256 clinical departments of 83 German hospitals during 2004/05 and identified a severe mortality tipping point at 92.5 per cent occupancy.
The discharge records of 82,280 patients with a high risk of mortality were studied and one in seven deaths could be attributed to occupancy alone, and could have been avoided if they were not exposed to such busy wards.
Prof Scholtes said: “We all suspected that outcomes would deteriorate, but previously there were assumptions of gradual deterioration. Our research revealed is that there is, in fact, a tipping point which was triggered strongly at about 92 per cent.
“When the tipping point was exceeded, patients began dying in significant numbers.
“If the tipping point is reached frequently, the hospital will experience a sustained quality problem, which may threaten its survival. Even more worryingly, if the tipping point is only exceeded occasionally, the dangerous situation may go unnoticed because it is not statistically detectable in aggregate hospital data. The hospital appears safe when it isn’t.”
Deaths also result as a consequence of central policy, the adoption of programmes and the cultivation of attitudes.

Talking about death or end of life care is not easy for anyone, but staff at Leicester’s Hospitals are already taking an active role in trying to improve the recognition and care of patients who may be close to the end of their life.
This is the ‘Quality End of Life Care for All’ (QUELCA) programme.
Rebecca Proctor, Macmillan End of Life Care Facilitator at Leicester’s Hospitals added: “I have discovered that empowering staff to recognise that patients might deteriorate and die soon is key and the training we are providing is helping ensure that these staff have the skills and confidence to provide sensitive, appropriate care in these situations.”

One such way is through the ‘Quality End of Life Care for All’ (QUELCA) training programme that is delivered to ward nursing staff by our Specialist Palliative Care team in conjunction with colleagues from LOROS hospice.

Rebecca, one of the lead facilitators of the QUELCA programme, said: “This has made a real difference to the understanding staff have of the issues for dying patients and their families.  With this increased awareness, staff have been able to identify issues and make changes that improve the delivery of end of life care in their ward areas.”  Examples of positive changes on individual wards include improving provision of refreshments, camp beds and space for relatives.

Dr Bronnert added: “There have been real improvements in care over the last year across our hospitals and we will continue to make many more improvements.  There has been a better recognition of patients who may not recover from their illness during their hospital stay and we have seen an increasing number of patients who have chosen to complete and carry with them ‘Emergency Health Care Plans’ that outline their preferences for care in the future, which means our staff can do their best to give their patients care that is tailored to their needs and what they would want.” 
Identifying and classifying as 'unlikely to recover' is a generalisation that may apply to a group but not to the individuals of the group. QUELCA is not at all a ‘personalised’ programme of care but another self-fulfilling prophecy.

Patients who 'carry with them' their own ACDs in the absence of up-and-running EPaCCs are bearing their own death warrants and providing justification for the withdrawal of treatment.

Ward staff are being delivered the confidence to 'recognise' these patients. A little knowledge is a dangerous thing.

A little knowledge in the hands of the arrogant and self-righteous, confident and secure in their own self-righteous belief, not at all tempered by humility, is a deadly and frightening thing to contemplate.

Further reading -
Liverpool Care Pathway - Boiling Frogs, Sans Everything

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