JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Tuesday, 13 May 2008

Palliative Care: Discussion.

Chairman

The purpose of this meeting is to receive a briefing from representatives of the Irish Hospice Foundation. I welcome Mr. Eugene Murray, CEO of the Irish Hospice Foundation, Dr. Doiminic Ó Brannagáin, chairman of the Irish Association for Palliative Care, Ms Mo Flynn, CEO of Our Lady's Hospice, Mr. John McCormack, CEO of the Irish Cancer Society and Dr. Sinéad Donnelly, consultant in palliative medicine, of the Irish Palliative Medicine Consultants Association. I particularly welcome Mr. Hugh Kane and Ms Martina Queally from the Health Service Executive, who immediately responded to our request to attend, for which I thank them.

I draw witnesses' attention to the usual practice whereby privilege does not apply to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House, or an official either by name or in such a way as to make him or her identifiable. Members may ask questions after the briefing and I ask that all telephones be turned off.

I will ask Mr. Murray to make the presentation on behalf of the Irish Hospice Foundation, following which members may ask questions. For how long does Mr. Murray intend to speak during the presentation?

Mr. Eugene Murray

I intend to speak for between 15 and 20 minutes, as requested.

Chairman

Will there be just one presentation?

Mr. Eugene Murray

Yes.

Chairman

The Irish Hospice Foundation is of the firm view that funding provided to hospices, particularly in the area of palliative care, should be spent specifically in that area. To support that view, figures will be given as part of the presentation. For the benefit of members, the presentation will show that, in 2006 and 2007, the Government allocated €18 million and approved 130 whole-time equivalent positions within the HSE.

The issue of concern to us is that all funding should focus on the provision of front-line care staff to develop badly needed hospital services. The HSE approved the appointment of 130 front-line care staff in 2006 and 2007. However, by May 2008, less than half that number had been recruited and only 20% of posts have been filled in the three least developed regions, the south east, midlands and north east. A further 47 whole-time equivalent positions were approved in 2008. Our main concern is that the funding for these posts may not be used for the purpose intended.

On 10 December 2007, the Minister for Health and Children wrote to Mr. Liam Downey, the chairman of the Health Service Executive, making the point that there could be no question of diverting development, capital or long-stay repayment funds to meet expenditure pressures arising in regard to core services. In other words, we are firmly backed up by the Minister's letter in our view that funding allocated to palliative care should be specifically directed to that area.

I invite Mr. Murray to make his presentation.

Mr. Eugene Murray

I am delighted to attend this meeting of the committee. Several organisations are represented here. I speak on behalf of the Irish Hospice Foundation, which does not provide direct hospice services but plays a role in the development of hospice care in the State. Mr. Doiminic Ó Brannagáin is chairperson of the Irish Association of Palliative Care, which represents staff working in the service. Also here is the chief executive officer of the Irish Cancer Society, Mr. John McCormack, along with Dr. Sinéad Donnelly of the Irish Palliative Medicine Consultants Association, and Ms Mo Flynn, chief executive officer of Our Lady's Hospice, Harold's Cross.

I will go through the first six pages of my presentation quickly. There is a strong commitment in the programme for Government to address the regional inequalities in palliative care. The funding provided to date follows on from that commitment. I draw members' attention to the diagram on the third page of my presentation which refers to a policy adopted by the Government in 2001 during the tenure of the Minister for Foreign Affairs, Deputy Martin, at the Department of Health and Children. This arose from a report of the national advisory committee on palliative care which proposed a structure and resourcing mechanism to ensure hospice services in all care settings would be available to patients.

The inpatient unit is the hub of the service. For example, Raheny hospice has 19 beds and 130 patients in the community receiving home care. The same is true in Harold's Cross and Marymount. What is required is a service that includes home care, day care and inpatient beds. Unfortunately, that is not widely available but at least the policy has been agreed by the Government. That policy must be implemented in the five-year period of the Government's term. If targets had been met, we would not be having this meeting.

A baseline study was conducted in 2005 which benchmarked where we are vis-à-vis the national policy. It indicated significant regional variations and core deficits in funding which would require almost a doubling of funding to €140 million. This was accepted by the Minister for Health and Children when the baseline study was launched. Page 5 of the presentation includes a bar chart which shows the significant variations in statutory spending per capita. There is a commitment to equity in all health strategies and a commitment that services to patients should not be determined by where they live. However, the spend per capita in the midlands is €1.30 compared with €33 in the north west. Parts of the State are falling badly behind others in this regard.

On the next page locations are given as an example of inpatient units, where hospices are located in Raheny, Blackrock, Harold's Cross, Cork, Limerick, Galway, Sligo and Letterkenny. There is no hospice in the four counties of the south east: Carlow, Kilkenny, Wexford and Waterford. There is no hospice in the four counties of the midlands: Laois, Offaly, Longford and Westmeath; or the four north-eastern counties of Cavan, Monaghan, Louth and Meath.

These are examples which have been pointed out and on which there is engagement. We have development committees in each of these regions and the HSE is working on a five-year plan. We are not here to talk about the five-year plan and we accept there are plans to locate hospices in Waterford, Kilkenny, Drogheda, Cavan and Castlebar. We know there is a five-year plan coming down the tracks and we should keep our fingers crossed that public finances will be available to meet that target.

We know difficult times are ahead and the main focus of today's presentation is to identify that funding flowed in 2006, 2007 and 2008, which has now disappeared. We do not want to focus on a five-year plan but rather on the money that is being provided to address these deficits.

The next page makes a quick reference to a commitment, based on evidence from a baseline study and the national plan, from the social partners to address these deficits in Towards 2016. Former Taoiseach, Deputy Bertie Ahern, made very specific commitments back in December 2006 that we needed a framework to address these issues. We have a commitment in the national development plan to address the deficits.

I will mention the cancer strategy, as we speak about radiotherapy, oncology and surgery. We know, unfortunately, that 50% of people who get cancer die within five years. We know that palliative care, unfortunately, is a very significant part of the cancer journey. We recently had the very sad case of Nuala Ó Faoláin, who passed away and whose funeral is today. I am glad she availed of hospice services in Blackrock. It is really important when talking about cancer services that we bear palliative care in mind.

Many people who do not have access to palliative care are in more expensive parts of the health service. Palliative home care is a cost-effective service. The national development plan made a commitment on the issue.

To get to the core of the matter, we will consider what happened in 2006 and 2007. In 2006, the Minister provided €13 million, €9 million of which was to be spent in that year. There was a carryover of €4 million in 2007. It was allocated generally across the regions to address specific issues, for example, putting new beds into facilities in Blackrock and Milford.

One of the matters which emerged from the baseline study was that many home-care teams were funded by the voluntary sector. For example, the home-care team in the west of Ireland, in Galway, is still 100% funded by voluntary contribution. Nurses' salaries are paid by people going out and collecting money, which is contrary to national policy. In 2006, the Minister allocated funding to increase the percentage of home-care funding by the State in north Dublin from 20% to almost 70%, in the midlands from 20% to close to 50% and in the south east the increase the figure from 20%. There was some movement although it has not been evident in the west of Ireland.

In 2005 we did a children's needs analysis. We have no children's hospice services in this country. The Irish Hospice Foundation is committed to providing 50% of funding in that regard and we fund some nurses in the children's hospital in Crumlin.

Over 2006 and 2007, eight community nurses were provided for in whole-time equivalents. Today only two of these remain and we are told that the other six posts are now gone, as is funding for them. This is a service provided to 1,300 children living at home in the community with life-threatening illnesses. The funding was provided based on evidence and planning and it seems to have disappeared.

Moving on to 2007, another €9 million was provided, with an extra 70 jobs. Again, the money was distributed fairly evenly around the regions. I will now go through the four regions and explain exactly what happened. Before I do this, however, I must mention that the letter included here from the assistant general secretary of the Department of Health and Children, from which I do not intend to read, gives an indication that when funding is allocated based on evidence-based planning by the Department and approved by the Department of Finance, specific instructions and letters go with this funding to the HSE. We can see on the relevant page an extract about monitoring and control, and the importance of having a detailed framework and quarterly reporting on implementation, including expenditure and numbers of posts. This was the intention, but I am afraid it did not happen. If we go to the following page we will notice that even by the middle of 2006 the alarm bells were ringing. The funding was not coming down for the purposes intended. The national advisory committee on palliative care engaged with the HSE, asking where the money was and what was going on. We were given assurances at the time that we should not worry because this money was in the budget and it and the posts would be there forever. Over the past two years we have always been assured that despite the slowness in getting going, the money and posts would not disappear. Unfortunately, what we realise is happening as we move into 2008 is that these assurances have not been delivered on.

As members know, the four HSE regions are amalgamations of former health board areas. It is almost true to say that in each of these regions there is a strong hospice service that is highly valued and regarded. I must say in fairness to the HSE that where it works it works extremely well. If we consider the Southern region, we find there is a strong service in Cork that is highly regarded. A day care service has now been developed in Tralee and there is a plan for a satellite unit there also. In the south east, however, there are no inpatient beds and the service is poorly funded. Over the two years of 2006 and 2007, 11.5 front-line care staff were approved, but today only three of those are in post. We find that overall in the southern region approximately half of the posts that have been approved are in place.

Let us now move to the Dublin/north-east region. This contains the former Dublin north region, including St. Francis's Hospice in Raheny, which has a strong inpatient service and good home care. There is currently a plan to build a day care facility in Blanchardstown and eventually an inpatient unit in west Dublin. Again, money flowed into the St. Francis's Hospice and was used. We have a unique multidisciplinary home-care service in the four counties of the north east, led by Dr. Ó Brannagáin, who is here today. However, if we consider the number of posts approved over two years in the north east region, we see that 23 front-line staff were approved, of whom only six are in place. We then move on to 2008, in which year there were supposed to be additional funds. Those working in services in the north east were told that €1 million will be sliced off their existing budget and we find that staff who leave are not being replaced. Staff are being told, for example, that a particular occupational therapist post is no longer needed and that the whole-time equivalent is to be used to add catering staff to one of the hospitals. It is quite extraordinary what is going on out there. Over the whole region, six out of 26 posts are in place.

I will now move on to the Dublin/mid-Leinster region. Earlier I mentioned the midlands, where the situation beggars belief because history is repeating itself. In the five years from 2001 to 2005 the Department of Health and Children provided €1 million to develop palliative care services in the midlands but the money was used for services other than palliative care. In 2005 we were promised that the money would be returned and, since then, an additional 15 posts have been approved in the midlands. In fairness, the HSE has increased the statutory funding of the home care team and taken on occupational therapists and the local planning people in the area of palliative care have been very engaging.

Hopefully there will be a hospice in Tullamore because there are no beds in the four midlands counties. We have a consultant, having been the only region in the country which did not have one. Funding was provided for a second consultant, as every region should have at least two, but even though funding has been provided that consultant is not in place. Having lost €1 million, we in the midlands are now in the process of losing for the second time around.

In south west Dublin there are hospices in Harold's Cross and Blackrock and, while it looks like the funds and the posts are very safe, Harold's Cross hospice has not received €500,000 of the budget which it had been allocated in 2007 and 2008. It still has not been given an assurance by the HSE that the funding for 2007 and 2008 will be available. While it looks good on paper, there is no palliative care service in County Wicklow and there are no beds and no home care nurses. There is nothing in County Wicklow as of today.

In respect of the western region, I give credit where credit is due. The money flowed into Milford Hospice for ten beds and 33 staff. There seems to be a pattern whereby if money flows into a voluntarily-run hospice service it tends to get used. Unfortunately, where services are to be directly delivered by the HSE they tend not to happen and the figures jump off the page in that regard. I do not mean to come down on the local people because our engagement with local planners has been good and money has been flowing to HSE staff posts in the west of Ireland. However, of the €750,000 provided in 2006 and 2007 to Galway Hospice, only €25,000 was spent. I am glad to say that in April another four beds were provided and it looks like the tap is opening up in that respect. The situation also looks good in Mayo and Roscommon, although six of the staff are on temporary contracts and if one does not have a permanent post in the HSE today one is in danger. I hope beds come on stream in Mayo and Roscommon but the overall situation in the western region looks good.

In summary, 50% of HSE posts are not delivered and we would like the committee to write to the Minister and the chief executive of the HSE to tell them to keep to democratic wishes in regard to planned development. On budget day, the Minister brought proposals to the House, based on evidence, for protected development funding. The proposals were approved by the Department of Finance and passed in the Dáil. If we have a situation where he who shouts loudest gets what he wants, as opposed to following a planned approach based on evidence and best practice, we are only throwing our hat at the problem and that is what seems to be happening at the moment.

Members will see, in the third last page of the presentation, a letter from the Department to the HSE telling it what was to happen in respect of the €3 million and the 130 whole-time equivalents in 2008. This letter indicated the Department's intentions in regard to the funding. Those intentions are not being realised. The HSE has decided in its wisdom to use the 2008 funding to fulfil the commitments made in 2007. It is using the 2008 money to fill the posts it was supposed to fill in 2007 with the funding provided for that purpose. The money allocated in each year must be used for the intended purpose in that year. It is as simple as that.

I thank members for their time. My colleagues will be delighted to answer their questions. We have sought a meeting with the Government and the Department of Health and Children to discuss how these funds could have disappeared in this way. We have serious concerns that the commitments given in Towards 2016, the national development plan, the cancer control programme and the programme for Government will not be realised. If we cannot protect the resources that have been allocated, there is no point in having all these policy documents and well-evidenced approaches. We appeal to the committee to do something to address this serious situation.

Mr. John McCormack

I support the points made by Mr. Murray. Anger is the only emotion I feel when I read his presentation and I am afraid I may say something I later regret. The voluntary sector, including the Irish Cancer Society and local hospice groups, has been providing support for palliative care for 20 years. The thanks we get from the State, however, is a failure to deliver on its commitments to those who have no voice. Many men and women with lung cancer and other forms of life-limiting cancers are at a vulnerable stage in their lives and need support. It is unacceptable that the money allocated for these services should not be delivered.

Ms Mo Flynn

Mr. Murray gave a clear indication of the impact throughout the State in areas where there are no services. My colleagues and I are involved in the provision of specialist palliative care in Cork, Galway, Dublin and Limerick. As of yesterday, across our six hospices, 27 people were awaiting admission to an inpatient specialist bed. In addition, some 126 people were seeking home-care services, either waiting to be discharged or at home awaiting some level of specialist input. Also yesterday, 46 people were on the waiting list for day hospice services.

In addition, I asked my colleagues in St. James's Hospital to give an indication of the numbers moving through their system. In the period from 26 March to 12 May, there were 94 referrals for palliative care, of which 66 were new patients and 28 were readmissions. Of this 94, 26 ended up dying in the acute sector and 28 were discharged home where they found they were unable to access home-care services. We were unable to pick up the referrals because our home-care teams are so overstretched. The average waiting time for a person to transfer to hospice care is some 8.2 days. The longest waiting time of which we are aware was 20 days. For some people, 20 days may be more than they have left to live.

We can talk a great deal about figures but we must also have a sense of the individuals waiting for services and the families in great need of our support. We must focus on what we can do to help them. This is our ability to meet those needs for physical, emotional and psychological care. Many people are left to languish whose needs we are not able to meet.

Whereas there are vast areas of the country without a service, it is worth bearing in mind that even in the areas where we are trying to provide services across Dublin, Cork, Limerick and Galway, we are very severely stretched in our ability to meet the needs.

Chairman

I thank Ms Flynn. Does Dr. Donnelly wish to speak at this point?

Dr. Sinéad Donnelly

I represent the consultants in palliative medicine, of which there are approximately 24 in Ireland. As the committee has heard, there are some areas with no consultant-led service. The idea in Ireland is that a consultant, a medical doctor, will look after a patient in his or her home, in the hospital and the specialist palliative care unit. Our national aspiration for Ireland is to have an integrated service, where the doctor and the rest of the team follow the patient.

What Deputy Micheál Martin instituted as Minister for Health and Children in 2001 was to be highly recommended, as Mr. Eugene Murray has referred to. The momentum which put us to the fore internationally — as a country we had a national policy approved by Government — is being lost, which is a pity.

With regard to consultants in palliative medicine, some regions have one consultant and others have more. It is very labour-intensive to look after someone who is dying. Not only does one require practitioners in different specialties in health care but these services must be sustained and supported. Not only do people need to be in place but one must be able to maintain staff. These are maintained by adding to staff numbers as appropriate.

Chairman

Thank you. Before I ask members to contribute I will allow Mr. Kane to make his submission. I welcome him and the representatives of the HSE. After the interview with Mr. Murray on "Prime Time", I made contact with the HSE and I emphasise that in this particular instance the HSE was more than willing to come to the meeting.

In view of the staff figures presented on that programme, I also offered the HSE the opportunity to have the meeting held in private. It is to Mr. Kane's credit that he indicated his preferred option would be to come to a public meeting. It is worth noting that.

Before we begin with Mr. Kane's presentation, I will make one or two points. It is fair to say that all members on this committee are concerned about this issue. We do not have the authority to raise funds within this committee but we can ensure that funding allocated within the budget is spent within guidelines and headings. In that regard we want to ensure the funding is allocated. We are not here to scapegoat anybody today but clearly it is a sensitive and difficult issue.

Normally we spend our time trying to source funding. It becomes a nightmare when funding is already allocated and is not being spent in the areas provided for. Figures presented by Mr. Murray concerned the fact that 50% of people who suffer with some form of cancer have a possible life expectancy of just five years post-diagnosis, and in that regard the programme as promised would be some comfort. The figures presented on "Prime Time " give rise to great concern.

I am from the midlands and I know Senators and Deputies will have their own stories. I never realised the area was as badly serviced until that evening. We have come to rely on the voluntary aspect of the work, and we feel that once the voluntary aspect is in place, there is no need for State support. We may not even look to see if it exists.

The figures outlined have shown that without State support or a proper lead-in or service, the concept of palliative care is diminished.

The points made about the voluntary sector mean we have to acknowledge it but not rely on it. The geographical spread of services underlines the fact we do not have the service. Coincidentally, I have two friends in the Gallery, Mary Seale and Margaret McNamara, who represent the Cuisle Centre in Portlaoise. Their visit to the Dáil was organised months ago. Mary Seale was on the "Prime Time" programme some months ago and they know what they are talking about. We want to see services of that nature throughout the country.

On the "Prime Time" programme, I gave a commitment on behalf of this committee to ensure that the funding allocated would be provided. That is not what one might call stretching our importance, but at the first meeting of this new committee we promised, as our mission statement — a phrase I dread, but it will come in handy at this point — that we would ensure proper scrutiny of all funding allocated within the health budget to ensure it would be spent in the appropriate areas. Against this backdrop, I wish to single out a particular point made by Mr. Murray on "Prime Time" and again this morning. We have to be aware that history will show that funding was provided, but we are not prepared to waste the morning talking about history. We want to be able to give a commitment today, which I will ask Mr. Kane to help us deliver, that funding allocated in 2006, 2007 and 2008 will be spent specifically in the appropriate areas. Even though the two previous years have now passed, the funding that was not used then can be front-loaded for 2008 and 2009. That is what we are about. If we as a committee cannot deliver upon that we should not come back to this room for further meetings. We are putting it as starkly as that.

We welcome the presentation of Mr. Kane and are fully aware that Mr. Kane does not direct policy issues at HSE level. This is his area and we are interested in hearing his viewpoint.

Mr. Hugh Kane

Before I give my presentation I must point out that I do not want my words to take from the very good work in which all my colleagues are involved in both the voluntary and statutory sectors. There is nobody in this room who has not been affected by this awful disease and the turmoil that occurs when people are terminally ill or watching their loved ones die. What we all want, both as public servants and as individuals, is to provide the level of care that people need in such difficult times. This is the context in which I give my presentation. As a public servant, that is the commitment I try to live up to, along with my colleagues.

There is a difficult question, which I will come to in a minute. However, in an overall context, the HSE delivers a range of services to those with terminal illnesses as part of its general services, within both the acute sector and the general community services. In other words, acute services are available to those who are terminally ill, while in the community we have what we describe as generic services, administered by GPs, nurses, therapists who deliver care every day on the ground in the same way. In addition, some specialist services, similar to the services delivered by my colleagues present today, are delivered by the HSE itself. Another plank of our funding is our significant funding of much of the work that is going on. That is the context.

I will now zone in particularly on the three years being discussed — 2006, 2007 and 2008 — because this seems to be the nub of the issue. A total of €3 million is approved for 2008, and this is in the system and will be on its way out. There is no issue of this not being applied as it should be. I want to be clear about that. I have those approvals and they are in process to go ahead. With regard to the €9 million for each of 2006 and 2007, what happened is that there were deficits across the range of services we deliver in both the acute and non-acute sectors. Some of these deficits arose simply because of unforeseen or increased demand. Under the Vote system, in which the HSE is allocated a particular resource to deliver within its service plan each year, when the level of service delivered is in excess of what we agreed in our service plan, certain decisions must be made around maintaining existing or core services, sometimes at the cost of increasing or developing new services. It would seem somewhat illogical to reduce the capacities of a core group of services while at the same time adding new services. A fine balance must be struck. In 2006 and 2007, the HSE experienced significant budgetary deficits. Under the Health (Amendment) Act 2004, the chief executive officer must live within the budget allocated for a given year. In seeking to balance the Vote, certain decisions were made to reallocate funding in particular streams.

Chairman

Was the funding that was specifically earmarked for palliative care in 2006 and 2007 withdrawn to fund other services?

Mr. Hugh Kane

Yes.

Chairman

Mr. Kane referred to unforeseen circumstances and increased demands. Perhaps I was naive in assuming there would be certainty in regard to the projected figures in cancer care. I do not understand how those figures could not be accurately forecast.

Deputy Jan O’Sullivan

Will Mr. Kane tell us who made those decisions?

Mr. Hugh Kane

It is difficult to separate out purely palliative care services in the context of the overall budget. Many of the generic general services in terms of acute and community care are already delivering. Deficits occur across the spectrum of services. At year's end, when we are trying to finish within the Vote, certain choices must be made in terms of the funding that may be applied to maintain existing services. Some of the palliative care funding, along with other pots of money, was diverted as part of this balancing exercise.

Chairman

That is the core issue for us. Having established the need for funding for palliative care and having earmarked a level of funding for this service in 2006 and 2007, are we to understand that it was subsequently considered a lesser priority in the league of health service funding? At what level was that decision made?

Mr. Hugh Kane

The decision was made by the national management team, comprising the chief executive officer, national director and director of finance. It was a question of balancing out the Vote, which is the chief executive officer's responsibility.

Deputy Kathleen Lynch

Is Mr. Kane saying the decision was made by Professor Drumm?

Mr. Hugh Kane

It was made by Professor Drumm and his management team.

Deputy Kathleen Lynch

How many people comprise that management team? I do not intend to put Mr. Kane through the wringer but merely to establish whether we are talking to the wrong person.

Mr. Hugh Kane

I have the lead on palliative care on behalf of the system. I conduct that business on a day-to-day basis.

Deputy Kathleen Lynch

Were you consulted before this decision was made?

Chairman

I ask members to direct questions through the Chair. Members will have further opportunity to ask questions in due course.

Deputy Kathleen Lynch

Was Mr. Kane consulted before this decision was made?

Chairman

I set a poor example for proceedings. Mr. Kane should be allowed to finish after which Mr. Ó Brannagáin will speak. I will return to Deputy Lynch later.

Mr. Hugh Kane

The chief executive officer is required to balance the books within the Vote allocation to the HSE. Certain decisions must be made, as happened in 2006 and 2007, across a range of funding streams to balance the Vote and meet the legal requirement under the Health (Amendment) Act. This is how some of the moneys for palliative care were diverted. The argument has been made that this money went into a black hole. That is not so. A major budgetary difficulty is the increasing cost of demand-led schemes such as the hospital drugs scheme where there were overruns in respect of specialist drugs for oncology and so on. Diverted funding was not lost into a black hole but was used to cover off sections of black holes within a range of services.

Dr. Doiminic Ó Brannagáin

I commend the Chairman on the clarity he is bringing to this discussion. He has homed in on the essential issue, which is that Voted money from the Oireachtas is not being used for the intended purpose. To focus on the patient's experience, I will borrow from the words of my colleague, Dr. Tony O'Brien, chairman of the advisory committee on palliative care. He stated:

Palliative care is about people. It is concerned with ordinary people who find themselves facing extraordinarily difficulty situations — the loss of independence, the loss of financial security, the loss of all that is safe and familiar, the loss of friends and family, the loss of future and, ultimately, the loss of life.

These people require an advocate, and that is what we are about today. We are advocating on behalf of these people. I simply cannot accept what Mr. Kane stated a moment ago regarding the need within the HSE to balance an overrun from one sector with voted development funds from this House.

The evidence shows that palliative care is cost-effective. In other words, we do better than others with the same amount of money that might otherwise be spent. When I hear that overruns on drug budgeting from oncology, for example, would be shored up by money not spent on palliative care, I cannot accept that.

Currently in Ireland, there is no specialist palliative care service that is over budget. They are all under budget and have these voted allocations from 2006, 2007 and 2008 that have yet to be applied.

I remind members what palliative care is about. It is about providing services to people of all ages. I have seen children four days old receiving palliative care, as well as patients in their nineties. It applies to people with all diagnoses, not simply cancer. Many of these people receive the services from time of diagnosis. The evidence shows us that one in four people who have a diagnosis of cancer will die within a matter of years. They require palliative care from the time they are diagnosed and cannot afford to wait.

The effects of not applying these moneys for their intended purposes affect us daily in our ability to predict, from one day to the next, whether we can provide a service to a patient. People do not ask for an awful lot. A study undertaken by the Irish Hospice Foundation three years ago looking at the preferences of patients, if they knew they had a life-limiting illness, showed three preferences. The first is to die at home, with the second being free of pain and suffering. They also wish to be surrounded by those whom they love. Not having these moneys means there is a slower response on the part of statutory and voluntary services in providing what these most vulnerable people require.

My service in its current guise is six years old. We have never had a waiting list in that time up to the present. We have occupancy of 58% of the voted number of posts we have, which means we are down 42% of our staff. We have a waiting list for the first time in six years.

This means only the sickest of patients get a service. We have had to limit our service to five out of seven days in the week, although we know people can get sick on any day of the week rather than on a Monday to Friday. We end up with precipitant hospital admission, so people who might otherwise be cared for at home end up in hospital unnecessarily. There are knock-on effects from this in the hospital system. We end up with patients who have increased length of stay in hospital as they cannot get home because they are not able to access the services required to remain at home. After these patients die the families are left bereft of bereavement services.

That is the effect on friends and families of not applying these moneys.

Chairman

I will hold it there for the moment on the response from the HSE and I will call members in the order they have indicated to me. They are Deputy Jan O'Sullivan, Senator Phil Prendergast, Deputy Kathleen Lynch, Deputy Rory O'Hanlon, Deputy Margaret Conlon and Deputy Bobby Aylward, in that order. Deputy Jan O'Sullivan is the Labour Party spokesperson on health.

Deputy Jan O’Sullivan

What we have heard is disgraceful and I do not blame Mr. McCormack for being angry. I thank Mr. Murray and all the representatives for their presentations. I fully support the Chairman's statement that this committee must insist that the money for 2006, 2007 and 2008 be delivered for palliative care as originally intended. What we have heard about is a total breakdown in accountability and policy implementation. We are talking about a policy document that has not been implemented. Whoever is responsible — it is not Mr. Kane, and we do not intend to apportion any blame to him as he is clearly not in control of this — has diverted money away from one of the most important areas in which it could be spent, and we must ensure that it is diverted back. The principle of equity has totally gone out the window.

Mr. Murray gave us figures which show that some regions are not getting their fair share in this most important area. I represent an area that is getting its fair share. I am familiar with the tremendous work of Milford Hospice and the home care teams. They strike an excellent balance between good public funding and good voluntary fund-raising, because they are terrific voluntary fund-raisers. It is a model of best practice. Everybody in the country should be entitled to this level of care. The money was allocated but was spent in other areas. Apart from the human side of things, based on what Dr. Ó Brannagáin said, it is clearly not even cost-effective to keep people in an acute hospital when they could be in a hospice setting. Budget control seems to be all-consuming in terms of decision making within the HSE.

I do not want to apportion blame but to try to find a solution, as the Chairman said. However, I put down a parliamentary question on 17 April about this and the cancer control programme, and I was told by the Minister that since 2006 additional funding totalling €21 million had been provided by the Government and that this allowed for enhanced service provision. I would have thought the Government also had a role in ensuring the money it provides is spent in the way it is intended. There has to be a role for Government here apart from dishing out information in a parliamentary question without having any idea whether the money allocated was spent on what it should have been. With regard to accountability and responsibility, the Minister must also take responsibility for ensuring that money for development in areas such as palliative care — and mental health, in which area we have also heard money was diverted — is spent for the intended purpose. If there is one thing we do in this committee it should be to ensure this happens in the future.

I realise I should ask questions as well as make statements. On the headings under which the money was allocated will Mr. Kane say if it was under the budget of the National Hospitals Office or the PCCC section? I presume the Chairman wants to get the answers at the end but I ask Mr. Kane to mark that question. I do not know where it was allocated and that is why I asked the question. Money that is allocated to the Hospitals Office budget seems to be used in all sorts of ways, while money allocated to PCCC does not appear to be spent at all in some cases. According to figures in yesterday's newspapers, there were 2,206 over-allocated posts in the acute hospital sector and 2,551 under-allocated posts in the community sector. I presume some of Mr. Kane's work is in the community sector.

Mr. Hugh Kane

All of it.

Deputy Jan O’Sullivan

Therefore, his section has clearly been robbed by the acute hospital sector. I do not know if that is unparliamentary language but that is what has happened.

I also ask for clarification on staff. Mr. Kane told us about whole-time equivalents and so on, but I ask him to provide more information on the kind of work these people would do if they were appointed as promised. What is the expected timeframe for providing hospices and the associated care teams in every region? What would Mr. Kane like this committee to do? We cannot allow this practice to continue.

Senator Phil Prendergast

I thank the delegates for their presentations. I am appalled at what we have learned. Of the €21 million allocated to meet the continuing delivery needs of the palliative care service throughout the State, only 25% to 30% of that figure has been spent for that purpose. The go-ahead has been given for the release of the €3 million that was held back this year. Will that release take place immediately or will it be a lengthy process? When will the €12 million that was redirected by the HSE in 2006 and 2007 to cover core deficits be reallocated to vital palliative care services?

The embargo on staff recruitment is having a major impact on service delivery and is causing disruption in services to those in great need of them. Many staff who retire or take maternity leave or leave of absence are not being replaced because of this embargo. This is having as significant an impact as under funding or the redirecting of funding. I am aware of at least one area where the palliative care service has been reduced by one third. This is probably replicated throughout the State. Will Mr. Kane detail whether any services are available in south Tipperary? In the circumstances of starvation of funding, where approximately 75% of assigned funds are redirected, how can the multidisciplinary team continue to provide the same level of service to this vulnerable sector of society?

Mr. Kane made a brave decision in coming to this meeting. He is not the person making the decisions at the highest level. I do not wish to patronise him by saying that. However, palliative care is a vital component of the health service for patients with cancer, multiple sclerosis, Parkinson's disease and other diseases, disorders and illnesses that require such care. How can an increased demand for cytotoxic drugs, for example, justify a diversion of allocated finds for palliative care? There is an absolute need for such drugs; it is not something that comes out of the air. Any system should have built into it a capacity to provide vital services and treatment within budget. There should be no redirection of funding from services considered to be of lower priority.

I am aware that there are many competing demands. Last night's report on "Prime Time" will lead to further pressure in regard to how we do our business. I will observe with great interest how this issue is addressed.

Deputy Kathleen Lynch

I welcome the delegates. I very much appreciate the clear information they have provided. Sometimes we find ourselves trawling desperately through reams of figures but that is not the case here. The information is so clear because it is so obvious. The hospice and palliative care movement in Cork is very well served by Marymount. Apart from providing end-of-life comfort to people approaching that stage and their families, it has taken the mystique and fear from dying. Anybody who has come into contact with the people involved would realise that very clearly. That is probably the case everywhere the hospice movement provides a service.

The reason the delegation got such a good reception this morning is that members of this committee probably feel as duped as it feels, if they deliberately went out of their way to ring-fence an amount and then it is siphoned off because somebody else cannot keep within the budget. I take on board what Mr. Kane has stated about overruns and unforeseen demands. This was one area where there was very clearly a foreseen demand. There were two specific reports on it and it was mentioned in two other reports. We know exactly what the need is and what needs to be developed. The notion that because somebody cannot keep to the budget, money specifically set aside for this area and the mental health sector is hived off to support other areas is unacceptable. We know Mr. Kane did not make these decisions and we should make that very clear. We appreciate him coming along this morning. Was he asked about it or was he asked to make an argument as to why it should not happen? Is there a level in the HSE that does not have to ask anyone what their needs are?

There is an argument that the Minister for Health and Children created the HSE to put the health executive at arm's length from politicians. However, it has gone from her own control. Who should we ask about this money and who made this decision? Maybe we should get Professor Drumm back in here. The man spends more time in here than we do at this stage. One wonders what the benefit is of that.

Who made this decision and how was it made? Was it documented or were the people in control of this department asked about it? Were they asked what the money was for and if it was ring-fenced?

When we first came into this committee, we were asked to specify what we expected to do. The one thing on which we all agreed was that we should make the HSE accountable, not in respect of its actions but in how money was spent and how we could determine where that would go. That was one of our priorities. It has not happened.

Mr. John McCormack

It is not happening.

Deputy Kathleen Lynch

It has not happened. We are trying to be as helpful to Mr. Kane's area as possible but we need to know about these issues. How do we get the people responsible for this and how was the decision made? What process was used and how do we get the money back?

Chairman

I do not want to create the impression that we are totally devoid of any contact with the Minister or Professor Drumm. On 18 June we will have both the Minister and Professor Drumm before the committee. In advance of their arrival we will put the proposal hinted at a few minutes ago by Mr. Murray. Before the end of this meeting we will put together a proposal from the committee that will go to Professor Drumm and the Minister before our meeting.

I will continue with the questions as they are all related. That gives the witnesses some time to come back on the issues.

Deputy Rory O’Hanlon

I welcome the delegation. I am glad to see such a high-powered delegation here because we certainly have a very high level of professionalism and commitment. We appreciate the work done by the various organisations in the hospice movement and everybody associated with it in what they do for the people who need their services. They ensure these people have dignity, and as Dr. Ó Brannagáin stated, they can die at home, without pain and with family and friends around them.

In our discussions, we are talking about palliative care in isolation, as if it were a standalone service. As no town in my area has a population of more than 10,000 people, it appears there is a need for very close integration between acute hospital and residential and community palliative care teams. Ms Mo Flynn mentioned St. James's Hospital and its relationship with the hospice. Does the delegation think improved relationships with acute hospitals would have an impact on the budget?

Our discussions highlight the problem for health services in all countries — insufficient resources to meet demand. We face the challenge of how to prioritise to ensure we provide the highest quality service within the available budget. I will illustrate this point. The five major Dublin hospitals have practically the same budget as I, the then Minister for Health, had for the entire health service 20 years ago. It is a question of how we prioritise our needs.

I share the concern of my colleagues that the money voted for palliative care is being diverted to other services. There is a need for greater communication and co-ordination between the Health Service Executive and the providers of services. I would like to think it should never be necessary to reduce the allocated funding for services such as palliative care. I was glad to hear Mr. Hugh Kane say that the 2008 allocation would be honoured, but is there a possibility that something may arise in 2008 that would reduce this allocation? I together with my colleagues would be pleased to speak to the Minister on this issue to ensure that the allocated funding for palliative care will be paid.

In the course of his remarks Mr. Eugene Murray stated that it was contrary to national policy, but I am not sure to what he was referring?

Mr. Eugene Murray

The home-care nurses in Galway are funded 100% by voluntary contributions, whereas the State funds 90% of the staff cost of the provision of the same service in Limerick and Cork.

Deputy Rory O’Hanlon

While I accept that what has happened should not have happened, what was said in public session could be misconstrued. The co-ordination of voluntary and State sectors provide the best possible service. The voluntary sector is able to make a contribution the State cannot make for a variety of reason. I accept the point made by the delegation, but as I see it, we should continue to ensure we have integrated voluntary and State sectors so that we do not put too much of a burden on the voluntary sector.

Deputy Margaret Conlon

I too welcome the delegation and thank Mr. Murray and Mr. Kane for their presentations. Like the rest of my colleagues, I do not agree that funds dedicated specifically to the provision of palliative care should be diverted to meet expenditure pressures. However, I accept that we must all live within budget. I feel strongly about this, coming from the north east where we have a significant deficit and are constantly reminded that we must live within budget. However, it should not be cut at the front line where people are most vulnerable. In this case we are talking about people in the latter stage of their lives who deserve to die with dignity. They deserve funding for the services they need. It is difficult to stomach the fact that this depends on where one lives. If one lives in the south, if one is serviced by the centres at Milford or Marymount, one has high quality services. In the north east there is no hospice service. People must depend on the Cavan and Monaghan hospice movement to constantly fundraise to provide a level of service for patients. Outcomes are probably not as good in that area because we do not have the services we should have and deserve to have. However, outcomes would probably be much worse were it not for the hospice movement there providing a service voluntarily. As Deputy O'Hanlon said, working together and having an integrated approach ensures a better outcome for patients. It is best practice. I note that all the specialist palliative care services came in under budget. If the money dedicated had been spent, there might not have been overruns in other areas. Cloth is being cut one way when efforts should be made to ensure money is ring-fenced and spent to prevent overruns in other areas. There is an important lesson to be learned.

I share Deputy O'Hanlon's concern in regard to funding for 2008 and the fact that if something arises, some of that money may not go to palliative care services. One outcome we should hope for from this meeting is to see money allocated spent for the purpose for which it was intended and a marker put down for future years. That is something we must work at. We must also see what can be done to retrieve the money diverted in 2006 and 2007.

Has the hospice movement had contact with Professor Tom Keane and is it working with him on the cancer strategy? What is the level of communication and dialogue?

Deputy Bobby Aylward

Like my colleagues, I am very disappointed at what I have heard today. I compliment the groups represented and Mr. Hugh Kane who have come to explain why money was diverted. I am aware the reason relates to budget control in the past two years. How do we rectify a wrong? I see it as a wrong. The money was approved by the Government three years ago. There are commitments in the national development plan, the cancer control programme and the programme for Government, but two years on, there is already a deficit. How can it be made up? Can we ever make up the funding that was lost to these invaluable services?

I come from the south east and I am disappointed to see that only 20% of approved posts in the south east have been filled. I have seen these bodies working at first hand. They give dignity to people who have cancer and are terminally ill. The hospice in Kilkenny gains most of its funding from voluntary contributions. It must seek voluntary funding in order to provide a service which gives dignity to people who are terminally ill. What is society about if not caring for the elderly, the sick and people who are dying?

It is never too late to rectify a wrong. I accept that we must live within budget and I am worried that the flow of money into the Government's coffers is not as great as it was. If we were not able to fund this service in 2005, 2006 and 2007 how will we do so in the future, when we already have a deficit?

I ask Mr. Kane to impress on the people who make these decisions that society's first duty is to care for people who are sick. I accept that people are being cared for in hospitals and in other ways but care must be made a priority. The health system is assisted when people are cared for in their own homes among their families. Otherwise such people use the resources of our acute hospitals. Are we being penny wise and pound foolish? Would we not be better spending money on treating patients in their own homes rather than putting them into hospitals? Would that not save money?

I support everything that has been said. This committee set out with the aim of analysing the HSE and getting value for money from it. This is an ideal point to start. Any influence this committee has should be used to ensure that the HSE changes its direction with regard to funding the bodies which are present at this meeting. This money should be restored to the services which deserve it. I support the proposals 100% and I wish the bodies concerned the best of luck for the future.

Chairman

We will begin our process when the Minister attends the committee on 18 June. Before that, we will have made our case to the Minister and to Professor Drumm.

Do you have a question, Dr. Ó Brannagáin?

Dr. Doiminic Ó Brannagáin

It is important that members appreciate that before we got to our present position we examined and established the need throughout the country. Need assessments have been completed in each of the ten former health board areas. Those needs were prioritised by committees representing all key stakeholders, voluntary and statutory organisations, and presented to the Department of Health and Children for consideration prior to money being voted to the HSE. That undertaking has already been given.

Deputy O'Sullivan asked what the effect would be of releasing that money into the system and what sort of people could be employed. We are talking about combinations of doctors, specialist home-care nurses, clinical nurse specialists in hospitals and allied health professionals such as physiotherapists, occupational therapists, medical social workers and pastoral care workers, all of whom would provide services to patients wherever the patients are. As Dr. Donnelly has said, the service moves with the patient. It is an integrated service and, I contend, a model for the HSE of how to do business and provide services for patients.

We are showing the way. There is a cruel irony in the fact that we are doing things properly, gathering the evidence, making our case and having money voted to us but are being punished because other people are not doing their jobs correctly.

Mr. Eugene Murray

Let me clarify one point.Mr. Kane has stated the sum of €3 million for 2008 will be applied. Let us remember that we are half way through the year and not one penny has been spent. I draw attention to the third last slide in the presentation. Subsequent to budget day, a letter was sent by the Minister to the HSE outlining the areas in which the sum of €3 million was to be used. A sum of €800,000 was to be used in Dublin north east, mainly for special palliative care inpatient services. I know Dr. Ó Brannagáin has managed to secure premises on the grounds of Our Lady of Lourdes Hospital in Drogheda for inpatient beds on an interim basis in the north east where there are no inpatient beds. My understanding was that a refurbishment plan was in place to provide the first specialist palliative care beds in the north east and that this funding was going to make it possible. With regard to the sum of €500,000 for HSE west, I referred to this earlier in terms of the Minister recognising that there was an issue to be addressed in the west. In fairness to her, she addressed the matter in the south east, midlands and Dublin north in previous years. The west had been left out of the equation.

I did not refer to this is my presentation but I wish to quote from a letter from Mr. Kane's predecessor, dated 12 February 2008, to me, Dr. Ó Brannagáin and Mr. McCormack and copied to the Department of Health and Children. It reads:

The use of the €3 million budget funding will proceed as soon as possible. This funding and the whole-time equivalents will be used to implement outstanding developments from 2006 and 2007 which have not yet been implemented.

We are being told that the funding provided for the years 2006 and 2007 is gone and that they will use the allocation for 2008, not for the purposes for which it was allocated but for the purposes of what was allocated the previous year. He went on to say:

In parallel, a reserve list of entirely new developments is being developed to the value of €3 million. This reserve list and any remaining 2007 developments will proceed as soon as the financial position is reviewed at the end of the first quarter with a view to confirming the key financial targets set in the HSE service plan are being met.

There is a slight promise that possibly if the HSE has the money, it might do it, but our experience, unfortunately, has been that the message from the people on the ground who are receiving these funds is that they are being asked to allocate them to developments meant to be undertaken in previous years, not to the developments indicated by the Minister in the direction to the HSE in December. These are the facts.

Mr. John McCormack

I will comment briefly on the overspend on oncology drugs. We have a cancer crisis that is getting worse. We have 23,000 cancer cases. By 2012 this figure, with our ageing population, will increase to 47,000. The message must be sent that the necessary resources to fight the battle against cancer must be provided. There is no way out of this. Money cannot be found elsewhere for it. We must plan to provide the money. We have a national cancer control programme and Professor Tom Keane who has the support of the Minister has the bit between his teeth, but will we find ourselves before a committee in three years engaged in a similar discussion on palliative care and central cancer care services? It is important that this does not happen.

The tradition when it comes to funding services is not great. We hope we will have cervical screening services in 2008, 20 years after they were introduced in the United Kingdom. It is important that we grasp the nettle and focus on providing proper amounts for these services; otherwise the position will be very serious because of the numbers coming down the line.

The relationship between the voluntary sector and the State sector is a partnership. We have been doing our bit by raising money. The State has not been doing its bit. It is rather sad. Fine letters, from which Mr. Murray has quoted, written by the Department to the HSE are no good, unless people can be held to account for their actions and the Minister for Health and Children can sit down, perhaps, with Mr. Liam Downey, chairman of the HSE, with a checklist of things she wants done, as we must do with our bosses and chairpersons to whom we are accountable for the actions of our organisations. It is important that such a system should operate between the relatively new HSE and the policy setter, the Department of Health and Children.

Dr. Sinéad Donnelly

In response to Deputies Conlon and O'Hanlon regarding our links with Professor Keane and the integration of palliative care services in hospitals, although most people would like to die at home, most die in hospital. Some choose hospital as the place where they wish to die. It is, therefore, important that palliative care services are well integrated in hospitals. As a result, the length of stay for an oncology patient in, for example, Limerick, would be 2.9 days. That is so tight and so short because the palliative care services pick the patient up as appropriate and thus facilitate his or her discharge and look after him or her at home.

Professor Keane, coming from British Columbia, had a different idea of palliative care services but is beginning to understand how well integrated palliative medicine and care services are with oncology services and how we work so closely alongside them and that that is what we would like to happen in all of Ireland.

Chairman

We have had an hour and a half debate. I will now hand over to Mr. Kane who, I hope, will be allowed to respond uninterrupted. Mr. Murray will then wrap up on behalf of the Irish Hospice Foundation and I will wrap up on behalf of the committee and propose something before the delegations leave today.

Mr. Hugh Kane

I will go through the questions asked. In response to Deputy O'Sullivan, each pillar of the palliative care services has generic funding. Specialist funding for palliative care services is provided through the PCCC.

A number of members asked about the sum of €3 million. It is protected because I have it in my system rather than in anybody else's. When I took up the post, I moved to do this in order that it would be ready to be given out. That will happen in the next few weeks. Priorities were identified previously, outside of the funding for 2008, which seem urgent. I propose to go with these now and, based on how we get on in the rest of the year in trying to influence other amounts of money that may be available, try to lever further funding.

On the sum of €12 million, it is not in a bank account waiting to be spent. It was spent in delivering front line services in 2006 and 2007. The only way such a sum of money could be returned would be to take it from another part of the HSE system. I will take the comments of members of the committee back to my CEO and advise him of the committee's strongly held view.

On what is involved in the process, I have been in this post only since the beginning of the year; therefore, I was not involved in any decisions taken last year. I know that we work on position papers and argue within processes for the individual care areas. That is the process during which competing bids are made for people across the system.

On the embargo on staff recruitment, there was an embargo for three months at the end of 2007 that applied to the HSE. The embargo ceased on 1 January this year. What we have in place now is a rigorous control mechanism governing how we will fill posts as they arise. The position since the beginning of January has been that if somebody goes out, somebody else comes in. We look at that vacancy and at all other vacancies and try to prioritise posts. Since January 2008, if a post-holder leaves, his or her actual post may not be refilled. It may be determined that something else is more urgent.

Deputy Jan O’Sullivan

How come there are more than 2,000 extra posts in the acute hospital service and a similar number unfilled in primary, community and continuing care? How can that be, if every post-holder is replaced when he or she leaves?

Mr. Hugh Kane

This system is in place only since 1 January 2008. At the end of 2007, the census showed that the hospital sector was overmanned and PCCC was undermanned. In HSE terms, the numbers balanced out. Since 1 January last, we have a different regime. Through the employment control framework which is now in place, we are trying to ensure that some vacant posts on the acute hospital side will come back to PCCC so that when a post is vacated in the acute sector a decision can be made as to where the replacement can be most efficiently deployed. Since the beginning of January, everyone who leaves the health service is replaced. We simply ensure that the vacancy filled is in the front line and the one which most urgently needs to be filled. That is the issue with regard to the embargo.

People have zoned in on oncology drugs. I simply gave that as an example. Across the general range of services, from which we all benefit, particular deficits arose. That is where cross-funding is required to balance out the Vote. I hope I have addressed members' questions.

I have no difficulty in meeting the committee. It is important that I do so. My colleague and I have taken extensive notes so that when the committee meets our CEO in June he will deal with the issues raised.

Mr. Eugene Murray

We hope the committee will raise these issues with the Minister and the CEO of the HSE when they attend the committee in June. We hope the committee will communicate with them in advance of the meeting so that they are aware of the evidence regarding palliative care. We would appreciate it if the committee would engage with them on this subject.

I acknowledge the attendance of Mr. Hugh Kane and Ms Martina Queally. We work closely with them. They are committed public servants and we look forward to working with them in the future. Much hard work has been done on a five year plan. Mr. Kane did not come here today and talk about the five year plan. He addressed the issue raised. I acknowledge that.

In today's edition of The Irish Times, I read that the Taoiseach, when replying as Minister for Finance to a question by Deputy Shortall, referred to additional posts and services for elderly, palliative care, disability and cancer services. He went on to say that in this regard the HSE will be required to redeploy more than 2,000 posts to PCCC. We have lost 50% of our 130 posts so, assuming we can keep the 47 posts for 2008, we are only looking for between 65 and 70 jobs. In the context of a health budget of €14 billion, what we are looking for is pretty small but hugely important in maintaining the integrity of existing services. If the redeployment mentioned by the Taoiseach takes place, I hope that among the 2,000 new posts in primary care we can find those 60 or 70 posts. Following the committee’s meeting with the Minister and CEO in June, I hope we can hold on to the 130 posts that have been funded from 2006-2007 plus the 47 from 2008, making a total of 170 posts, and that they can go to provide the front-line care of which we speak.

On behalf of my colleagues in the Irish Cancer Society, the Irish Association for Palliative Care, the Irish Palliative Medicine Consultants Association and the Association of Chief Executives of Hospices, I thank members for giving us this opportunity today.

Chairman

These meetings can often be occasions for making political capital but Opposition members have not gone down down that road, for which I thank them. I thank them for recognising that we must deliver on the commitments to provide funding which have already been secured and voted upon. The €12 million to which Mr. Kane referred is not just lying there. The committee can never give in to pressure from demands for funding to be allocated or increased under a particular heading but, once promised, funding should remain secure. We will pursue that issue with the Minister and Professor Drumm when they come before us in the hope the funding agreed for 2008 remains intact. It is important for us to recognise the positive prospects for palliative care services and to ensure they are not confined to certain areas.

I also believe in the five-year programme and hope it can become a reality. I go along with the proposal that we should not just depend on it but backdate the commitments made. This issue arose in the midst of public concern for Nuala Ó Faoláin who is being buried today. However, it did not take what happened to her for us to realise what needed to be put in place.

I thank Mr. Kane and Ms Queally for coming before us today. We always tell HSE staff who come before us that we do not hold them specifically accountable for national policy decisions, that we take up such matters with Professor Drumm and the Minister. We promise to do so. We assure delegates that we do not invite them before the committee to say "hello" and make them feel good as they leave. We want to ensure their concerns will not have to be revisited next year. As Mr. McCormack said, once this issue has been resolved, there will be others surrounding cancer care and treatment in which we hope to become involved. We will deliver on the promise we made and it is up to us to ensure the funding will be allocated. I thank the delegates for their presentation. I also thank members for their contributions.