Professor Doiminic Ó Brannagáin:

I would like to come back to a couple of issues. Mr. O'Dwyer spoke about resources. The minimum need for inpatient beds and staffing that would exist across an entire integrated palliative care programme is described in the report of the national advisory committee. If we could wave a magic wand tomorrow to provide the additional €75 million that is required to deliver such a programme, we would have a major challenge on our hands because we would not have the staff required to deliver all of those services. That brings us back to the issue of education; specifically, the question of whether the education that is required in an inpatient context takes place in a specialist palliative care unit, a hospice or an acute hospital. As has been mentioned, there is no inpatient capacity whatsoever in three areas of the country. As a result, our ability to train people locally who will stay locally is relatively non-existent. That might not be appreciated by health care planners when they are considering this challenge.

I would like to make another point about education. Palliative care is part of the undergraduate curriculum in many of our medical schools, but not all of them. A module on palliative care is offered in many of our nursing schools, but not all of them. Such a module is not provided, in the main, when occupational therapists and physiotherapists, etc., are being trained. My view is that it should be a mandatory part of the basic formation of all health care professionals that they should have core competencies in palliative care. The postgraduate training of doctors and nurses in the medical, surgical and paediatric areas should enable them to maintain their skill sets and thereby ensure they are able to provide palliative care for patients in whatever context they are being cared for.

I would like to respond to Deputy McLellan's question about a public awareness campaign. There are no plans to ramp up the messages to which I have alluded. I believe they need to be getting into the public domain. When most people think about palliative care, they understandably associate it with hospice care.

However, they do not fully appreciate the health care benefits of early incorporation of a palliative care approach into the care management of the patient. I am speaking as much for the general public as for health care professionals. The discussion that takes place needs to be a dynamic process, where the doctor may offer it and the patient is able to respond in an informed way. This would be helpful and worthwhile.

To return to the issue of the acute hospital and the range and depth of services. As Drs. Ryan and Creedon have stated, we have some form of specialist palliative care available in all 42 acute receiving hospitals in this country. However, in the main these are "in-reach" services. Clinical nurse specialists may be based in the hospital, but the numbers are insufficient for the number of acute beds in hospital. Only a handful of hospitals in the country have a seven-day presence of consultants who can provide a same day response to patients, including out of hours. This is an issue that must be addressed.

I was asked what my piece about integration back into hospital means. There is a dichotomy of views in regard to this issue within the palliative care community. I am not speaking for or advocating an either-or approach, but that both approaches should be adopted. There is a need for specialist palliative care units and where they exist as stand-alone off hospital campus units, there is no reason there should be any change. However, we should have an open mind with regard to incorporating specialist palliative care units into acute hospitals also, because of the clear benefits I have ascribed to them. This discussion is at the early stages here. This is inconsistent with the approach in North American and mainland Europe, where service provision of inpatient beds is dominant within acute hospitals.