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NHS England to review unplanned admissions care plan following ‘do not resuscitate’ controversy

NHS England is reviewing the care plan template for the unplanned admissions DES following the recent controversy over a ‘do not resucitate’ question.

The forms would be reviewed in light of ‘poor patient experiences’ reported in the media, NHS England told Pulse, after the Daily Mail alleged on Tuesday that care coordinators for the DES were ‘callously’ asking patients to sign DNRs as part of some of the questions on the form.

The questions are included towards the end of the template form, developed by NHS Employers, NHS England and the BMA, and titled ‘Other relevant information (‘if appropriate)’.

The form states ‘[Was] emergency care and treatment discussed’ - adding: ‘if yes, please specify and outcome e.g: cardiopulmonary resuscitation – has the patient agreed a DNR or what treatment should be given if seizures last longer than x do y etc.’

Pulse revealed earlier this month that palliative care leaders were warning the unplanned admissions DES could cause harm to elderly patients if GPs were forced to treat it as a tick-box exercise.

This came after Pulse revealed NHS England issued strict guidance to its area teams that they should offer no leniency over DES deadlines, including completion of the 2% of care plans, creating fears GPs would be forced to ‘cut corners’.

Pulse understand that any reviews of guidance will have to be done in conjunction with the GPC and NHS Employers, and is awaiting further information from NHS England on future use of the form.

NHS England’s chief nursing officer Jane Cummings said: ‘There is one question on the form relating to emergency care and treatment and it mentions resuscitation as a possible discussion point.’

’Clearly if this conversation is appropriate for the patient, and as the form suggests it might not be, then it should be handled with great care.’

‘Just as it is important for nurses to listen to patients, it is important for the NHS to listen to patients and patient organisations.’

‘We will review the form again, with patients and clinical staff, in the light of the poor experiences described in the media and make any changes that are needed.’

The story broke when health commentator Roy Lilley revealed that his mother’s care coordinator, a district nurse who they hadn’t previously met, asked the questions while discussing the care plan. There were also reports of the questions on DNR being asked over the phone.

GPC deputy chair Dr Richard Vautrey said that the GPC had published its own guidance for GPs but explained that NHS England’s overly rigid interpretation meant these results were inevitable.

‘This is a classic example how an idea has been taken by over-officious managers, and turned into something that wasn’t intended. It’s these perverse outcomes that we see as a result of that.’

So I think whilst the review that NHS England has indicated is welcome, I think they need to go further than simply looking at this particular tick box, they need to look at the whole thing and ensure that practices do have genuine flexibility to deliver this in a way that is meaningful.’

Dr Vautrey added that: ‘What practices need to ensure, is that those who are acting on their behalf interpreting and developing care plans and discussing with patients, use their clinical judgement.‘

‘It comes down to common sense really, and being willing to stand up to those who want to over scrutinise this.’

Readers' comments (22)

  • Nhsfatcat

    Looks like they will scrap the whole thing and put the money back into the global sum.
    'What's that nurse? Medication time, again?'

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  • well, it is a farce - we are doing so many of these, and then the patients are dying - so we are having to do a bunch more.
    If they are done properly they do take time, but if you are doing care plans that are useless you can easily do them again - yet we dont have the time do this.

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  • Am interested in Simon Ruffle's comment, and would back that suggestion. Who on earth is advising the DH? Most proposals seem to have a very strong Nurse/Pharmacist bent, and quite frankly I am losing all confidence (which by the way is unlike me as I suprisingly still love my job and the current GP role!).

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  • I saw that box on the care plan and I decided that it was a step too far, so I automatically ticked no, deciding to face the possible wrath of the probity inspector.

    It seems I was right to use my common sense. You have to question the sanity of NHS England to include such a bomb in the list of questions.

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  • the DH is listening and rowing back. we could be cynical, but another slant to this is lets use this to rebuild relationship. we can't do our jobs effectively without each other.

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  • Yes, the Department of Health is listening to public outcry.
    Pity it did not listen to GPs in the first place.

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  • I didn't like the way the issue was phrased on the care plan template, so re-designed it for our patients to give them the autonomy over how and whether this was discussed. We have included one page in our care plan which states at the top: "Complete some or all of these boxes if and when appropriate. The following questions might help you to think about your care and how we can help you and respect your wishes. Your care co-ordinator will be able to discuss these questions with you at your request". It is then followed by free text boxes for patients to think about and complete if and when they want to, perhaps with family or friends, including "Where would I prefer to spend my final weeks and days?", "If my condition could not be cured, and no more treatment was available, would I want to be readmitted to hospital if this wouldn’t help my long-term outlook (providing my symptoms could be controlled without going to hospital)?", "If my condition could not be cured, and no more treatment was available, and I was approaching the end of my life, would I want someone to try and resuscitate me if my heart stopped beating and I stopped breathing", "Any special requests with regards to how you would like to spend your final days?" and finally "These things worry me about being terminally ill or dying…....". We have explained to each patient about the information contained, and then at follow up, will offer to discuss any issues raised with them. This avoided the problem of confronting patients with something they might not be ready to talk about and allows them to approach it in their own time. So far, the feedback we have received has been positive, and some patients have really welcomed the opportunity to discuss it.

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  • Assign responsibility to those responsible for the DES, the deadlines, the forms and the reconsideration of the forms - NHS England.

    If the forms are being reconsidered, and the reconsideration needs consultation with GPC and NHS Employers (in August?!?), what happens to the deadlines which LATs have been told to enforce rigidly and regardless of the late issuance of guidance?

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  • Nhsfatcat

    Listening, really?
    Roy Lilley has been active in the health service for many years and is very well connected. If he speaks lots of people listen. If GPs speak we're whining again.
    If we can get Roy and others who know what they're talking about on our side ( which also mreans better care for patients) we'll be better off. BMA GPC RCGP have no teeth as we aren't united behind them. (Remember the day if [in]action?)
    The answer is freedom from a contract that demands we need to see patients on our terms. Demand a dr/patient relationship, not a dr/contract one.

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  • we have a list size of 8k and we will lose 1200 aptts to cater for this non evidenced based tick box excercise. So we have now to face the music for the lack of availability and accessibilty. This is a scenario of treating certain groups( a minority 2%) as 'special' and ignoring the rights of the many.

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