Liverpool Care Pathway

Debate between Robert Flello and Rosie Cooper

Tuesday 8th January 2013 Westminster Hall

[Rosie Cooper (West Lancashire) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Weir. I congratulate the hon. Member for Montgomeryshire (Glyn Davies) on securing this essential and timely debate.

As hon. Members and the Minister will know, opinions on this end-of-life care framework tend to be polarised, but I believe that fundamental questions need to be answered about how the Liverpool care pathway has fallen into such disrepute, when it was developed to help doctors and nurses provide quality end-of-life care for the dying. That involves palliative care options for patients in the final hours or days of life, not a procedure that some members of the public now regard as a way prematurely to kill off the terminally ill or senior citizens.

The hon. Member for Montgomeryshire has outlined the process in which the Liverpool care pathway should work, involving significant communication if possible with the patient, but certainly with their next of kin and family. I share his support for the framework when it operates properly and allows the dying to die with dignity and free of pain. Why are there so many stories in the press of distressed families complaining that they did not know that a relative had been put on the pathway? The huge problem lies in the human application of the rules, not necessarily in the rules themselves. One in three families of those dying say that they never received the leaflet explaining the LCP process that they should have been given. Why is it not mandatory to evidence in the notes discussions with the patient or the family about the Liverpool care pathway?

Some would say that the difference between a multidisciplinary team decision, taken with the family’s knowledge and consent, and a decision taken in isolation could be seen as murder or at least manslaughter. The stark reality of the Liverpool care pathway is that 57,000 patients a year are dying without being told that efforts to keep them alive have been stopped. In some respects, there are parallels with the cases of Mid Staffordshire NHS Foundation Trust and University Hospitals of Morecambe Bay NHS Foundation Trust, which were supposed to be operating the same system as that in every other NHS trust in the country and yet somehow ended up abjectly failing their patients, so that people died unnecessarily. The sheer scale of the failure to inform people, or their relatives, that they are on the pathway opens up the practice to attack.

People talk about back-door euthanasia and some say that it is tantamount to assisted death, except that in 57,000 cases people were not aware that they were being assisted. That has to be added to the cocktail of the timing and the context of where we are now. The NHS is saving £20 billion over four years. There are service pressures—the lack of available beds and severe cuts in social services budgets that result in bed blocking, together with the demands of an aging society—but, frighteningly, as we have become aware via the press, at the same time hospital trusts receive financial incentives for achieving certain performance targets in putting people on the Liverpool care pathway.

Let me be clear—not for one second am I suggesting that those factors are part of the decision-making process; I use them merely to highlight the fundamental problem of the pathway and the perception that exists in the wider public, especially among the elderly.

Why do hospital trusts require any financial incentive to follow the Liverpool care pathway? For me, that question goes to the very heart of our national health service and our absolute understanding of what the medical profession stands for in people’s eyes. We believe that it is the role of the NHS and medical professionals to take every conceivable step to preserve life until the options are exhausted. The Department of Health has proposed to enshrine in the NHS constitution, as a patient right, an entitlement to be informed of any consideration about placing a patient on the Liverpool care pathway. Why can that not be made a legal requirement, so that everybody knows—and we are sure that everybody knows—and can be assured that taking such a decision is right?

[Robert Flello (Stoke-on-Trent South) (Lab)]

I add my congratulations to the hon. Member for Montgomeryshire (Glyn Davies) on securing this important debate. To go back to the hon. Lady’s point about the financial incentives for hospitals, it appals me, too. Surely, if patients or their families are not consulted, the Liverpool care pathway is not being followed, so any payment by the Department of Health to a hospital for having supposedly had someone supported by the pathway is money paid wrongfully, deceitfully and possibly unlawfully. Does she therefore agree that the Department should tell hospitals that have failed to consult family and friends or the patients themselves that the Department wants back some of that money?

[Rosie Cooper]

That takes me back to my earlier point that we should document the conversations with families, so that that would be the tick box for payments. I am running out of time, so I shall move on quickly.

Will the Minister elucidate how the NHS constitution requirement will make a difference? Procedures are already in place, yet 50% of patients on the pathway were not informed, or their families were not consulted. It is time that the soundbite, “No decision about me without me” became a principle and a value, rather than the vacuous phrase that it currently is. There is no politics in that—it is really important; it is the core of everything.

Through Lord Alton of Liverpool, I am aware that Liverpool medical school requires all its students to undertake one month’s training in the care pathway, working in a hospice during their fourth year. Such good practice should surely be a core component nationwide, and in the light of a recent study, there is perhaps an argument for making it mandatory across the country. That kind of training needs to be given to those already qualified and working on our wards—not just doctors, but nurses and all members of the multidisciplinary team who are called on to make decisions. If there have to be financial incentives, they should follow the training to ensure that all those who care for the terminally ill and dying are properly equipped with the skills that they need, in what for all concerned are traumatic and often complex situations. Good training costs money and must be externally validated, and I invite the Minister to respond specifically about that need.

I see merits in a system that manages end-of-life care effectively—it is a measure of our humanity that we seek ways to ease suffering—but my concerns about the application of the Liverpool care pathway remain. There is far too little reassurance in the system, which has allowed the pathway to move from an end-of-life care system to one that is held up as hastening death. We can talk about the theory of how the LCP should be followed, but the fact remains that, in practice, it is not always implemented as intended. It should never be seen as a conveyor belt to the cemetery. Some 80,000 patients are supported by—not put on—the Liverpool care pathway, and many receive the finest care, but many is not good enough. It is said that about 1% of cases go badly wrong, but just one case—never mind 1% of cases—is one too many. Those who founded the pathway did so because of their respect for the dignity of patients; those who implement it need to understand and share that view or face the legal consequences and their own consciences.