Ms Sharon Foley:

Some of my answers will be combined answers to various questions. Senator Burke asked about 92% of patients being referred in one week. If there are no specialist hospice in-patient beds in a region patients cannot be referred. The HSE simply cannot meet that target.

Several people talked about legal issues and emigration. I reiterate the point that end-of-life care and our approach to death, dying and bereavement is much wider than health. That is why we are calling for a national end-of-life and bereavement strategy.

To encourage people to deal with the legal matters involves raising the debate about dying, death and bereavement in Irish society. Advance planning then becomes part of one's natural life. One plans for the end of one's life when one is well and gets on with living one's life. It should become an everyday practice.

There are things that can be done now. As we speak, the HSE and the Department of Health are drawing up their service plan for next year. The committee can play an important role. There is a need to protect the budget that is allocated to specialist palliative care, protecting hospice home care.

Somebody asked a question about the impact of a hospice home care team on patients. The team is able to come into the home and provide that care at home. It makes a huge difference to patients at the end of life. If a team has a patient with complex needs who requires a bit more care and they cannot provide that care at home, they have no choice but to transfer that patient to the hospice, if they are lucky enough to have one in the area, or the acute hospital. They play a hugely important role but they need to be supported. We have a concern about hospice home care. Invariably, it is provided by small teams comprised of four to ten nurses, which are easily affected by cuts to budgets. One must deal with sick leave, maternity leave or people leaving, or the team may suddenly be halved after a budget cut. That has an impact on the ability to deliver hospice home care.

I reiterate that one of the things that can be done is for projects that have been earmarked to go ahead is to move from a preplanning to a planning stage. Senator Crown spoke about the choice of care location and promising people a good death. In our larger submission, members will see that we outlined all the elements that contribute to a good death. Some of those are well beyond our control. A good death is in some ways a facet of whether one has had a good life, building up good family and social supports, whether one has a belief system, and how society supports people who are dying, so we cannot promise all of those things. However, there are things we can do now to make things better. What we would like to see in a broad end-of-life strategy is the taking into consideration and pulling together of all of these wider elements to produce a coherent road map for the next five to ten years.

Senator Crown spoke about the need to improve skills in acute hospices. We have been advocating for that for a long time. In the past year, the clinical care programme for palliative care has developed a competency framework which has involved all the partners. That is about increasing the skills of health care staff at all levels of the health care system so they have the requisite skills around palliative care and are able to deliver care. We would like to see that competency framework developed.

My response to Senator Crown's and Deputy Neville's questions about what is being done to plug the gaps in the different areas is "Not enough". In the midlands, we have funded a piece of work to look at what might be the care needs of patients in hospices. It found the equivalent of 18 full-time beds are being used all the time for patients with palliative care needs. In respect of the earlier point about much of the budget being spent on end-of-life care, it is there and is being spent on end-of-life care, but we do not know where it is being spent and it is largely unco-ordinated and unplanned.

My colleague will talk about the regulation of the funeral industry. In terms of trends in cremation and the uses of cremation, we do not have the figures to date but all we know is that demand is rising, it is a very unregulated area and it is something that needs to be developed. In respect of the communication strategy, requiring our staff to have good communication skills around end of life is one thing, and we must provide the training and education. If any member wants to take part in any of our training and communication courses across all the Irish hospitals, we would be happy to provide the training or even come into Leinster House to provide that training. Communication in respect of staff is also a facet of the general capacity of our society to talk about dying, death and bereavement. There needs to be a better and more open debate in Irish society about the need to plan ahead and to consider and plan for people who are dying.