Dr. Brian Creedon:

I will continue from Mr. O'Dwyer's point about the economic arguments in the Chairman's question in terms of the HSE engaging in regard to these costs and potential efficiencies. It is difficult because it is a complex area. The HSE is quite fragmented in terms of budgets and so on. When one looks at the total system perspective rather than at individual components, there are potential savings to be made in the acute hospitals and so on from the effective use of palliative care.

Another difficulty is that we are in fiscally challenging times. Sometimes there has to be an outlay to get a return, which is very difficult at present. It has been demonstrated - particularly in Canada, which has quite a similar model of palliative care to ours - that when such care is resourced properly by empowering patients and providing high-quality care overall there is a reduced call for services. To extrapolate, this works if patients can access the care they need at home rather than having to present themselves to a hospital late at night, where no records are available, where they have tests done that may not need to be done, getting very expensive care that may not be the most dignified or comfortable care for them. That is not an efficient use of resources. The arguments lie in that area.

It is important to point out that there are costs, however, and although there may be savings overall, offering patients choice is also important. As Professor Ó Brannagáin said, some patients, perhaps those with a cancer diagnosis, will spend a lot of their time in an acute hospital and this may be the right place for them to die. They know the staff and are familiar with the services. We have to be careful about suggesting that all people need to die at home. The choice is theirs and it is contingent on other things. It may be related to whatever issues they are dealing with at the time, be these psychological or medical.

I will address a few of the other points made about the services that are provided in acute hospitals. We are fortunate that every acute hospital in the country provides palliative care, with palliative medicine consultants and palliative care nurse specialists in attendance. There are some deficits. The advantage in doing it this way, judging by my personal experience, is that we can facilitate the effective discharge of patients. Where families feel empowered such discharges are much more likely to be successful, from the perspective of the patient and the family, rather than having the revolving door scenario where somebody goes out and comes back in again 24 hours later because the discharge was rushed or things were missed in the details or in the planning of the services required at home.

Senator Crown asked about consultant numbers in Ireland. These are comparable with developed health care systems in the UK and Canada, but it is important to realise that we are seeing an increasing need for palliative care. As Professor Ó Brannagáin pointed out, given the increased work in acute hospitals and in dealing with people who have a multitude of illnesses, there may be a need for more consultants and other staffing resources, as well as in our fabric or infrastructure in terms of hospice beds and having community support beds to empower patients to be where they want to be, which is ideally as close as possible to where their families want them.

Senator O'Donnell's point is very important. A hospice is not the right place for everybody. It is about offering choice rather than being prescriptive, saying to people that if they have such and such a condition they should go to this or that place.