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Have We Lost Our Path?
A press release from the Department of Health on Monday heralded the phasing out of the Liverpool Care Pathway. Although the Review, headed by Baroness Julia Neuberger, found that in the right hands and when operated by well-trained, well-resourced and sensitive clinical teams, the LCP does help patients have a dignified and pain-free death. However, the blame for the change is laid on there being `too many cases of poor practice, poor quality care of the individual, with families and carers not being properly engaged in the patient’s care`. This finding, that it is in failings in the system and people and not the pathway itself, seems unfair to a good process. Should we not be dealing with the fundamental issues of poor governance, poor funding and poor staffing levels, all of which have been detailed as contributing to the inappropriate use of the LCP?
As an aside, Clinical Pathways are designed as `best practice` in all areas of healthcare, but they are only guidelines. Individual circumstances and the unique needs of every patient tend to put a few twists and turns into every use of a pathway. My training in pathways made it clear that it was OK to deviate from a guideline, if there was good reason and that this is carefully assessed and recorded. However, this was not being properly performed in some establishments.
Even doctors have their doubts about how the pathway was being applied. A Pulse survey of GPs found that many have lost confidence in the care the NHS provides to patients at the end of their lives, with 45% claiming they do not feel confident that the health service will give them a ‘good death’. Again, it wasn`t the pathway that was in doubt, just the way it was applied, with some citing the variability of services around the country and the vulnerability to funding cuts as reasons for their lack of trust in the service they would receive. There is an acknowledgement that the phasing out is due to bad publicity, so is this just a change of window dressing? NICE have not recommended any different end-of-life guidelines to the LCP, so I suspect the replacement will be similar, but with a different name.
The review of failing trusts published this week cites control of budgets coming before care. I hope the NHS will eventually be focusing on the needs of both patients and staff as individuals and not on financial targets.
Dr John Shapter - QCS GP Expert Contributor