Professor Declan Walsh:

I am grateful for the opportunity to speak to the committee. I have spent almost all of my professional life working in the United States and the United Kingdom and, therefore, my remarks will address the international trends in the field.

I refer to the field of palliative medicine, the physician specialty. It is a new and evolving medical specialty and its final shape and form is in evolution in terms of where it works, how it works and the various interactions it has a specialty. It is focused on people with serious or incurable diseases but its final shape and form is not decided as compared to a well-established specialty such as gastroenterology or cardiology. A major way of thinking about the management of chronic illness is to think of it in two buckets. One is the acute care system and the other is the post-acute care system of which hospice, rehabilitation and other forms of post-acute care are important components. The interaction between those systems drives much of the expense and many of the challenges in the management of chronic illness. The field of palliative medicine arose in part as a reaction to perceived deficiencies in modern medical care, for example, medical care being overly technical or impersonal in the hospital. This is starting to change because palliative medicine is becoming more of a mainstream medical specialty and that is a significant change internationally.

A patient who goes to see a palliative medicine specialist or someone who has had training in palliative medicine should expect superior skills and communication decision-making in the setting of a chronic complicated illness, excellent management of the complications of the disease and the symptoms such as pain, excellent care of the patient who is dying as well as psycho-social care of the patient and his or her family and co-ordination of the care to make sure the patient is in the right place at the right time for the right reasons. That is a significant challenge because it means the provision of services in the hospital or the community on a 24-7 basis. The current evolution of palliative medicine internationally is to go towards comprehensive integrated programmes that provide a menu of services in the hospital and in the community, which are linked, for example, by electronic medical records in order that there is excellent continuity of care between the acute care system and the post-acute care system and that the patient does not get lost in the medical care system. That, unfortunately, is a frequent occurrence with people who have complex chronic illnesses. Sometimes it emerges that nobody is in charge of the patient's care and that is one of the roles palliative medicine can fulfil.

The other major development is the so-called upstreaming concept. The idea behind this is that many people at the time they are diagnosed with an illness are diagnosed to be incurable at the day of diagnosis and, therefore, it makes sense to involve palliative medicine as a specialty early in the trajectory of the illness. There is persuasive evidence that early involvement of the specialty can reduce the cost of care, improve the quality of care and reduce length of stay in hospitals. People who have been referred to palliative medicine services early appear to live longer than those who are not referred until later in the trajectory of the illness. There are many benefits in terms of the quality and continuity of care and major economic and operational benefits for hospitals to have integrated comprehensive palliative medicine programmes.

In the context of the community, there is an inexorable shift away from the hospital into the community in medical care. This is driven by the ageing population and the realisation that hospitals can be dangerous places to be at times and people should be better cared for very often in the community setting. The explosion in modern information technology will allow us to look after people in a much more comprehensive and efficient manner in the community and we will be able to do things in the community that one could only do in the hospital until recently. This has significant implications for training, manpower in the context of the provision of specialists and generalists in the area and for returning to some old fashioned values in medicine such as the ability of GPs or specialists to visit patients in the home and so on. There are important services that need to be delivered on a 24-7 basis. There needs to be specialist back up for the community services throughout the country.

The international trends are earlier involvement of specialist palliative medicine closer to the time of diagnosis, the provision of integrated services between the acute care system and the post-acute care system to make the best use of the available medical resources in either setting and making sure the patient is in the right place at the right time. Palliative medicine is emerging as a mainstream medical specialty, which will have significant implications for the development of the field both in Ireland and internationally.