Dr. Margaret Clifford:

I thank all the members for their comments and questions. I will pick up on some of the points. When we talk about palliative care not taking place in a geographical location and about going to wherever the patient is, we need to bear a few things in mind. One is that we must be a little careful about the fact that the place a patient is in, particularly the place where he or she dies, is a very simple piece of information. It is black and white. One died at home or one did not; one died in hospital or one did not. We can access that information relatively easily because it is on the death notification form. We can get it from the Central Statistics Office. There is so much complexity around this point, however. When people are asked where they would like to be cared for, or to die, so many what-ifs are built into that. If somebody were to ask me that question I might say my choice would be at home, ideally, but that would only be so if I had about ten other different conditions satisfied. The way we interpret that information is important. When we talk about bringing palliative care to where the patient is, we must remember that the patient will be in many different places and circumstances throughout his or her illness. I echo what Dr. Creedon said about what we might say when we are talking about this as an abstract concept, when we would say home was the ideal. Home is not always the ideal, however. It very much depends.

What do we know about home palliative care? I refer to the evidence on this because it is so very difficult to gather evidence on the effectiveness of palliative care. The outcomes we effect are about matters such as comfort and quality of life, which are very difficult to measure. We know from a large review that brought together the results of 23 international studies that patients who received home palliative care services had significantly better symptom profiles and were more than twice as likely to die at home, with all the provisos we have mentioned.

I pick up on the point about education. We were talking, appropriately so, about education and training. We would need to have a broad view of that because such education and training take place in so many different ways. Of course it is about formal education, both undergraduate and postgraduate, and about training programmes. However, there is quite a lot of educational support that takes place in terms of the care of individual patients. I spoke earlier about the fact that palliative care and specialist palliative care are not synonymous. Not every patient who gets palliative care needs the direct care of a specialist palliative care team, but they need the specialist palliative care service to be sufficiently resourced to care directly for those who have more complex needs and also to provide that education we called "shared learning". It is a two-way process when we talk about educating our colleagues in other specialties.

There is an ongoing education and support role in terms of the care of individual patients. It is quite right that we are considering what we need to prioritise. I was asked specifically about home palliative care. I suppose we need to be very careful. At a time of scarce resources, when it might feel like less money is available for research funding, research is more important than ever. When we are prioritising, we have to know that we are putting time and money into interventions that improve patient outcomes. This means it is more crucial than ever to measure such outcomes.