Seán Crowe (Dublin South West, Sinn Fein)
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The committee will now consider the challenges facing community-based cancer support services in the context of the national cancer strategy. I am pleased to welcome from the Alliance of Community Cancer Support Centres and Services, Ms Gemma Fort, manager; Recovery Haven Kerry Cancer Support House in Tralee, Mr. Richard Flaherty, CEO; Cancer Care West in Galway, Mr. Conor O’Leary, director of operations; Purple House Cancer Support Centre in Bray; and Mr. John Conroy, manager, Dóchas Offaly Cancer Support Group in Tullamore.

Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

I invite Ms Fort to make her opening remarks on behalf of the Alliance of Community Cancer Support Centres and Services.

Ms Gemma Fort:

We thank the committee for inviting us to attend today to consider the challenges facing our services in the context of the National Cancer Strategy 2017-2026. We represent the network of community cancer support centres, which has a footprint in 22 counties, serving 26 counties. Our centres are affiliated to the Alliance of Community Cancer Support Centres and Services under the national cancer control programme.

The national cancer strategy aims to meet the needs of cancer patients in Ireland. It was developed to address future requirements based on the expectation that the number of cases of cancer will almost double by 2045. This is mainly due to an increasing and an ageing population as cancer is a disease where the risk increases with age. The objective of the strategy is to ensure that cancer services respond to the challenges and the opportunities for future development, so that care is of a uniformly high quality across our population. It also identifies that there is now an increased awareness and demand for additional support for cancer patients after diagnosis, including survivorship programmes and psychosocial services. Greater integration with primary care and local services is required to ensure seamless patient pathways before, during and after treatment.

The strategy recognises the contribution of the voluntary and community sector in providing services to cancer patients, their families, and carers.

We are here as representatives of a number of those centres. Over the past 30-plus years, a significant number of similar centres has been established on a voluntary basis by local communities in recognition of the wider needs of those impacted by cancer. Service provision has been driven by the needs of many cancer patients for ongoing psychosocial support both during active medical treatment and for a significant period after that active treatment is completed. More people are living with, and living beyond, cancer. Recognition of the ongoing health and well-being needs of survivors, as well as the consequences of their treatment, is important.

The role of cancer support centres as part of the circular integrated patient pathway involving acute, primary care and community services is recognised in the model of care for psycho-oncology launched in May 2022 by the Minister for Health. We provide a wide-ranging choice of free services to meet individual client needs, including the provision of information, counselling, psychological support and survivorship programmes, as well as complementary therapies, exercise and relaxation classes, support groups, financial advice, and drop-in services.

In 2022, almost 11,000 individuals accessed their local cancer support centre with more than 80,000 attendances at individual and group services. Last year, approximately 12,500 people accessed services - a 16% increase on 2022 figures with a 20% increase in attendances at individual and group services up to 97,500. Therefore, the need is growing. All services are provided free of charge to our clients. As one in two of the population is likely to have a cancer diagnosis and with an ageing population, this figure will only continue to increase.

Several challenges face our sector and need to be addressed to ensure we have the capacity to be sustainable. The first is the projected increase in cancer cases and the requirement to address the needs of cancer survivors. Trends and projections for cancer incidence in Ireland, published by National Cancer Registry Ireland show that there will be a continuing increase in case numbers for cancer - potentially a doubling by 2045 even after accounting for population growth and ageing.

There is a 50% increase in the numbers of cancer survivors compared with a decade ago, and for the first time, the number of patients living after an invasive cancer diagnosis has exceeded the 200,000 mark, equivalent to one in 24 people in Ireland, which is a very positive statistic. However, this has implications for our centres that are providing survivorship programmes as an increased demand for community-based provision of services is sought to relieve pressure on acute services.

The second challenge we face is the lack of annual guaranteed core funding which is a risk to our sustainability. Cancer patients and their families have identified psychosocial supports as a priority for living well with and beyond cancer. The HSE National Service Plan 2024 outlines a commitment to improving access to care and performance reports as a whole-system approach and is committed to progressing the development of psycho-oncology, cancer survivorship, child, adolescent and young adult services, and the community cancer support centre network.

These Government publications and national strategies acknowledge the value of our services and what we provide. Yet, we currently operate with no guaranteed core funding and each centre primarily relies on individually fundraised income to support its services. We need a sustainable model of core funding annually. Without this commitment, we face a real threat to our sustainability and capacity to respond. In addition, the objectives of the national cancer strategy will not be met, cancer patients will face even more isolation, loneliness, depression and mental health difficulties, thus placing an even greater burden on the acute medical services at a much higher cost than our services cost to operate.

Another challenge is with the provision of professional services and the costs associated with that. Over the years the psycho-social oncology model has evolved considerably, in line with more complicated client survivorship needs. For client safeguarding and well-being, individual therapies and group supports are led by suitably qualified practitioners. There are a number of evidence-based group survivorship programmes within our portfolio and a significant increase in demand for one-to-one trauma-informed therapeutic support, in addition to peer-led drop-in support which is evident in the cost-base for our centres.

Several of our members work with volunteer complementary therapists. However, it is increasingly challenging to recruit volunteer therapists leading towards a paid model which has significant additional cost implications for us. In addition, we have faced challenges in fundraising.

The Covid pandemic closely followed by a cost-of-living increase has highlighted the fragile and unsustainable nature of the existing funding model for our centres. The Wheel, in conjunction with Ecclesiastical Insurance Ireland, has published The Value of Giving 2022 report, which highlighted the challenges of charitable giving in Ireland. It showed that charitable donations had fallen by 16% due to the cost-of-living crisis.

Most grant-making organisations require applicants to create innovative projects and refuse to consider funding core services due to the once-off nature of their funding. Aligned to this is the time commitment and resources required to generate income from fundraising; time and resources that could be better used in service delivery and development. It is a high risk from a governance perspective to rely on the goodwill of our communities to support us through fundraising.

We also face an increasing administrative burden. As we have evolved in line with changing times, the administrative burden to ensure safe delivery of client services, the reliance on digital services and supports and the skill sets required for teams have all increased. Compounding the increasing demands on resources, we have also seen an exponential increase in governance and compliance requirements from stakeholders and funders. This is required to support good governance and we welcome that because it is very important. It has cost implications for our services.

The final challenge is the recruitment and retention in the charitable sector and we are not alone in experiencing this. Staff in the sector, across all salary scales, are paid considerably lower than their counterparts in the public sector. Potential applicants can be deterred from considering roles in our centres due to this difference in pay rates. Additionally, a perceived lack of stability in the charity sector significantly impacts the recruitment and retention of staff.

In 2024 we were collectively successful in securing €3 million in once-off funding from the Department of Health for 16 centres. We wish to express our gratitude to the Minister, Deputy Donnelly, and the Department for this initial allocation which alleviated some pressure on centres in responding to clients’ needs. We are seeking the provision of core funding on an annual basis to support responsible planning and development of services to respond to clients’ needs, support staff retention and ensure good governance in our sector. We are here today to ask the committee to support our call for the provision of core funding on an annual basis.

In 2024, the total operating cost for our centres which now have 26 members is €11.1 million. We are requesting a commitment to an allocation of €5.5 million in the 2025 budget, recognising that we will be able to contribute towards our operating costs. Annual core funding is vital to ensure the viability of the community cancer support centres and will allow our centres to: fund and maintain core services, which are provided free of charge; respond to increasing demand in our communities; and support those impacted by a cancer diagnosis at every point in their journey thereby enhancing their quality of life. This will only be achieved through properly resourced cancer support centres.

Seán Crowe (Dublin South West, Sinn Fein)
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I thank Ms Fort. I will now open it up to members who will each have five minutes for questions and answers. If we have time, we can then bring people back in again.

Seán Kyne (Fine Gael)
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I welcome the witnesses here this morning. Obviously, they have a very important role in cancer support. It is something that will impact many of us in the future. Every family is likely to experience cancer at some stage. How do people hear about community cancer support centres? Does it come through referrals from hospitals? I presume the hospital would be the first point of contact.

Ms Gemma Fort:

Referrals come from a number of sources. Healthcare professionals in the community and in acute hospitals and centres of excellence would make referrals. Given our presence in local communities - the centres are very much founded by members of the community - there is an awareness there. The service is accessible to anyone who needs it. I might invite one of my colleagues to speak because we are representing a number of geographical areas.

There is a good cross-section here as to where people are coming from and what happens.

Mr. Conor O'Leary:

To add to Ms Fort's point, the benefit of our services is that they are accessible in the community and very much living up to that primary care model so people can access healthcare needs where they live. People can self-refer when they are in their local villages or local towns where there is a local cancer support centre. They can just pop in, they will be seen and a treatment plan will be gone through with them. That is unique in terms of accessibility for a sector of community-based cancer support centres. The bedrock is volunteerism and community support but it means the most vulnerable in our society who are cancer patients and their families can have that access to the service.

To summarise the reply to that question, it is a number of referral sources and nobody is refused.

Seán Kyne (Fine Gael)
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I thank the witnesses for that. Mr. Flaherty is the CEO of Cancer Care West in Galway. The €3 million is obviously hugely important as once-off funding and the aim is to maintain and increase that. How important was that for the services for this year? What difference has it made and what more can the organisation do because of that funding?

Mr. Richard Flaherty:

It is critical. Before the €3 million, our centres represented a very diverse range of budgets ranging from annual budgets of €20,000 up to centres with a €2 million budget. Each centre gets a proportion of that €3 million and it has made a huge difference already this year.

Seán Kyne (Fine Gael)
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Is that based on their previous budget?

Mr. Richard Flaherty:

It is activity based and around footfall. This is monitored through the NCCP, which looks at the statistics every month. We submit statistics to the NCCP, which would allocate the funds. From my own perspective, we have two cancer support centres - one in Letterkenny and one in Galway - and prior to the €3 million funding the only allocation of funds for cancer support centres was section 39 funding. In its nature this funding is inequitable and is very ad hoc. There are some centres in organisations like ourselves that receive no funding through section 39, some centres receive a small amount, and other centres receive a significant amount. Even the nature of section 39 funding is ad hoc and unreliable, so we really feel there needs to be core sustainable funding for this sector. It cannot be left to fund itself. Our two centres cost €18,000 a week to run. Currently, we have had to rely on community fundraising, which is unsustainable into the future. The numbers coming through our doors have increased. Our stats from yesterday show that, for the first four months of this year, there was a 36% increase in the number of new cases.

We really feel that the €3 million is the first step on a journey and that €5.5 million would help us even more. We have more members with more needs and we need more resources in the centres. That is critical. The Minister and his Department acknowledge that. They acknowledged the work we did and the services we provide. The Minister also acknowledged that the funding model is not appropriate to support this sector. Our sector now is recognised in the NCCP. Our role in the cancer survivorship is acknowledged in the cancer strategy but the current funding model is unsustainable throughout the whole sector. We feel that €5.5 million in the context of a health budget of €23 billion is a drop in the ocean. The value for money that €5.5 million would give back to the Exchequer would be enormous.

This is related back to the patient. I always think of the young mother who was coming out of BreastCheck in Galway. She described herself as hearing cancer ringing in her ear. She got a bad diagnosis. The first port of call was to our support centre in Galway. Before she went home and before she could talk to her family, she came to the support centre and we supported her through her diagnosis, her treatment and her family after that. That role is replicated through support centres throughout the country. There is nowhere else for these people to go when they get that news. We are an important support to the patient and their family all through that journey. It is critical that this sector is now looked at independently and a fund is created to support it because the work we do on the ground is huge.

We talked about the reasons more and more people are accessing our services. The real reason is people trust us. It is also to do with conditions in the hospitals and the referrals. We are getting referrals because the hospitals also trust us. This is because we have a track record over a number of years providing evidence-based professional services to cancer patients and their families. Everyone in Ireland needs and deserves the best cancer treatment. We are currently playing a part in that and we just need some support.

David Cullinane (Waterford, Sinn Fein)
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I welcome our witnesses. I will start by giving a shout out to the Solas cancer support centre in Waterford in my constituency for the great work they do. I visited the centre last year in advance of the budget and the ask then was the same as is being asked now and which is the purpose of the meeting. I was blown away by the range of services provided. It struck me coming away from that visit and having communication with dealing with other centres since then as the national spokesperson for the party that in many ways community cancer support centres are the victims of their own success given where the organisations have now landed. When the organisations were first set up, they were voluntary and charity run. The centres were there to support families and cancer patients, but as time has gone on, the quality of the services, the professional nature of the services and the range of services has increased. We have now got to a point where the political system has to make a decision where we fund that and continue to provide the very high level of services that are provided or we allow them to depend on fundraising, which we know is not sustainable. Mr. Flaherty is right in saying sustainability is the key.

In that vein, I wish to ask about the fundraising side. Every charity organisation is finding it more difficult. Everybody is fishing in the same pond. The Irish Cancer Society was before the committee a number of months ago. There is the national cancer strategy and the lack of funding for it. As we know there is zero additional funding for 2024. Every organisation is trying to fundraise where it can, but if your funding is almost solely dependent on fundraising, it makes it very difficult to plan. Will the witnesses give us some indication as to the levels of money that may have been raised previously where it is more difficult now? This is just to give us a kind of picture as to how difficult it is in that space.

Mr. John Conroy:

I am from the Dóchas Offaly cancer support group. I am representing some of the smaller centres. As Ms Fort mentioned, we are a mixture of centres that are big, large or small. From a fundraising perspective it is absolutely impossible to create an annual budget. When we sit down at the beginning of the year to plan out our service plan for the year, we are looking at what the expected income will be and the hoped income. Then we try to budget services around that. With fundraising models we are so dependent on our communities. We really appreciate the communities.

David Cullinane (Waterford, Sinn Fein)
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My question is more about whether the centres have seen a drop-off.

Mr. John Conroy:

In terms of fundraising.

David Cullinane (Waterford, Sinn Fein)
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Over a reasonable time period, be it three or five years or longer, have the centres seen a drop-off in the level of fundraising or money coming in?

Mr. John Conroy:

Yes. Certainly our centre is well supported with fundraising but we have seen a drop-off. Since Covid there has been a marked change in fundraising and the types of fundraisers that are being done for us. Previously a lot of clients would have come in, availed of the free services and then would have wanted to give back and asked what they could do. We are seeing less of that. With our centre, the model of fundraising is very difficult because there could be periods where there would be no fundraisers for about six to eight months and we would be looking at the bank balance reducing. Then some big fundraisers might come in. Absolutely we are seeing a drop in fundraising.

David Cullinane (Waterford, Sinn Fein)
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Is it the precarious nature of it? I am trying to capture what is the big problem. As I hear the witnesses today, sustainability of funding is really important and the centres cannot plan for 2024 and 2025 if they are dependent on funding that may or may not happen.

Mr. Richard Flaherty:

On that point, one of the issues we have in our centres is that we are so closely aligned to the hospital with the critical referral pathways for patients, people think we are part of the HSE. They sometimes do not feel they need to fund for us. That perception is a challenge for us but we are community-based and reliant on fundraising.

Yes, fundraising on the ground is a challenge because there are many great causes out there. We all acknowledge that we are a long time providing these services and we are a long time fundraising. We have not come in looking for 100% funding, and we are delighted that the hospice are getting 100% funding. We know we will need to cover some of our budget through community fundraising and we are happy to do that, but we need a core base for each centre to be able to know that we at least have that much coming through and we can make up the gap. Now, the gap we need to fill through fundraising is too big to be sustainable into the future.

Ms Gemma Fort:

To add to that, that is our biggest risk. In the case of my centre, Recovery Haven Kerry, our operating budget has increased hugely since 2019. Post pandemic, more clients are coming through the doors. We have identified that we have kind of hit a threshold that we know we can raise locally through fundraising, but we are competing with other cancer charities that are doing very good work. As Mr. Flaherty said, there are many worthy causes in the community. People are now looking at doing GoFundMe pages, so that has changed. The gap for us is getting bigger between what we know we can generate and what we need to keep providing a quality service that adheres to good governance. That is the biggest risk as employers. Each of our centres employs staff to provide the service. Unless we have good governance in place, it is very risky for both-----

David Cullinane (Waterford, Sinn Fein)
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My time is up. I thank the witnesses for the work they do. It is fantastic.

Róisín Shortall (Dublin North West, Social Democrats)
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The witnesses are all very welcome. I commend them on the important work they are doing in all of the centres in supporting people through the cancer journey. It is no surprise that their work is recognised in the NCCP because it is so important that, from start to finish, that kind of support is available to people. The regrettable thing is that it is not available to people everywhere in the country. Nobody doubts the importance of the work.

Regarding the €3 million in existing funding, was that the first allocation the alliance got? It had no financial support before that.

Ms Gemma Fort:

That was the first allocation. We put in a pre-budget submission last year seeking funding. As Mr. Flaherty said, we had received some funding. This is the first time we have worked as a collective in this manner to pursue funding. Previously, each centre looked at its own funding in its own local area. However, it was recognised that we were perhaps stronger working together to highlight the need for core funding.

Róisín Shortall (Dublin North West, Social Democrats)
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It is just this year that the centres have come together.

Ms Gemma Fort:

We started working and coming together in June of last year.

Róisín Shortall (Dublin North West, Social Democrats)
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With regard to the €3 million, were they all separate allocations made to centres?

Ms Gemma Fort:

No. We put in a pre-budget submission and this funding working group met with the Minister, Deputy Donnelly, twice. Out of that, €3 million was allocated to the 16 full members of the alliance. By full members, it means we have passed the quality control programme of the NCCP. The €3 million is being divvied out through the NCCP. The 16 full members are receiving an allocation based on our activity levels last year but the funding is being given to us this year within the 2024 budget.

Róisín Shortall (Dublin North West, Social Democrats)
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How is the divvying out decided?

Ms Gemma Fort:

It was decided by the national cancer control programme on the basis of our activity levels last year. It looked at the number of new clients that each of us registered last year.

Róisín Shortall (Dublin North West, Social Democrats)
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The €3 million was routed through the NCCP.

Ms Gemma Fort:

Yes.

Róisín Shortall (Dublin North West, Social Democrats)
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I take it that the NCCP would fully support the alliance's pre-budget application this year.

Ms Gemma Fort:

Yes.

Róisín Shortall (Dublin North West, Social Democrats)
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Would the NCCP agree with the kind of figure the witnesses are talking about?

Ms Gemma Fort:

It would. We have kept it informed about the figures. It is aware. As Mr. Flaherty said, we are putting in figures to it on a monthly basis, so it knows the increase in clients we are seeing and the increased activity levels across each of the centres. It is aware of our operating costs as well.

Róisín Shortall (Dublin North West, Social Democrats)
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Given the importance of the support work the centres do, would the NCCP have any role in starting centres in areas that do not have them? I am looking at Dublin because I am a Dublin TD. There are many areas of Dublin that do not have centres, and I am sure the same applies all over the country. There is a big element of postcode lottery. Would the NCCP be initiating or recommending new centres to start?

Mr. Conor O'Leary:

I cannot speak for the NCCP but I am not sure it is at that point. To date, the existing centres have been covering those areas not served by a centre as best they can. That is the charitable nature of the Alliance of Cancer Support Centres.

Róisín Shortall (Dublin North West, Social Democrats)
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It is a patchwork.

Mr. Conor O'Leary:

Yes.

Róisín Shortall (Dublin North West, Social Democrats)
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Staff difficulties, pay rates and that kind of thing were mentioned. What staff would typically be employed in the centres?

Ms Gemma Fort:

It would be a mix. We have a mixture of nurses. Speaking for my own centre, we have two nurses and a counsellor who are our clinical team. We then bring in counsellors and play therapists to provide psychosocial services, and we bring in complementary therapists to provide that type of support. We are lucky in Kerry. We have eight complementary therapists who volunteer their time, but I know other centres have to pay complementary therapists. We are bringing in counsellors and complementary therapists to some centres. We are paying for counselling. Complementary therapists have to be paid. Obviously our core staff would be our clinical staff. We need administrative staff as well because there is a huge volume of administration and processing of numbers and figures. It is straddling client services and administration as well as therapeutic services. I might ask Mr. Flaherty, Mr. Conroy or Mr. O’Leary to come in.

Mr. Richard Flaherty:

I am seeing first hand the difficulty in recruitment. In our cancer support centre in Galway, we have three senior clinical psychologists who work around the clock counselling people individually. Unfortunately, one of our senior psychologists left the service a couple of months ago and we are finding it incredibly difficult to replace her. We are up against the HSE in terms of recruitment, pension entitlements and pay entitlements. It is definitely a challenge for us to recruit the type of staff that is needed when up against the HSE. It is a major challenge and it is one that will not be resolved overnight. It is proving a challenge for us because the workload is increasing. If someone drops off our services and moves away, we are finding it very hard to replace her.

Neasa Hourigan (Dublin Central, Green Party)
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I thank the witnesses for all the work they do. From some of the previous submissions, it sounds like the alliance has had some conversations with the NCCP about levels of funding required. Is that fair to say? Yes. Have their been any discussions around multi-annual funding and whether that is something the alliance should be looking towards?

Ms Gemma Fort:

We brought that very point to the Minister when we met him.

Neasa Hourigan (Dublin Central, Green Party)
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I think many groups have brought that issue to the Minister.

Ms Gemma Fort:

We did so because we recognise that it is too hard to try to plan year to year on the strength of what you might have in any given year. We are all operating on a yearly budget. It was fantastic to have the knowledge that we had the money coming in this year as part of the €3 million. However, we do not know about that money. That was given as a once-off allocation. That is where we are looking for the committee’s support to add weight to the discussions that we have had and that we hope to have with the Minister. I think he recognised the value, the work being done and the strength of the work. Mr. O’Leary spoke to him, so perhaps he would like to add to that.

Mr. Conor O'Leary:

Further to Ms Fort’s point, I refer to the risk. One-off funding is great, but what happens next year? It is difficult for us provide such high quality psycho-oncology and mental health supports to cancer patients if we can only plan, let us say, for this year, and then next year we are back to square one with a fundraising challenge. The evidence and research shows us that interventions and mental health and psycho-social interventions need to be provided at the time that the patient presents, particularly for children who are living with a diagnosis or living with a family member who has cancer. If they do not receive that support and if those issues are not treated at the time they present to their local centre, that will manifest and cost much more in future years – in their teenage and adult years. That is our biggest frustration. We are more than happy to provide these services.

We are willing and waiting and our centres are in place but we are limited by the scope.

Neasa Hourigan (Dublin Central, Green Party)
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I should just say that we often have organisations before the committee that, unlike the alliance, do have a sense that they will be receiving core funding every year but, again, that funding fluctuates year on year, which is equally challenging. I would be interested to know why the HSE or the Department does not look at three-year or five-year packages, which would allow for some kind of confidence as to future funding.

With the time I have remaining, I want to get a better sense of the post-pandemic context. I imagine that there was a backlog of people seeking services who had not been comfortable or confident to do so. This has had an impact on things like waiting lists and people's stress in accessing services. Will Mr. O'Leary talk not just about fundraising after the pandemic, but about any change in services or those trying to access them, which I imagine would have been very significant?

Mr. Conor O'Leary:

I have some statistics from National Cancer Registry Ireland. One of the big concerns from the registry's 2021 annual report was that a large proportion of late-stage cancers, 14%, were detected when people went to the accident and emergency department and that, during the Covid pandemic, the number of cases of cancer being diagnosed fell by 6%. As a result of these late-stage diagnoses, people are coming to us with more complex presentations. A different set of services is needed for somebody whose cancer is at stage 4. It is an even bigger challenge for us to have appropriately qualified personnel to meet those needs.

Neasa Hourigan (Dublin Central, Green Party)
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Does Mr. O'Leary envisage that levelling out at any stage or is it a demographic issue and a different context now?

Mr. Conor O'Leary:

This could take years to level out. Cancer is now a chronic illness and many people live with it for many years. It is about survivorship and helping people to live not just at the time of diagnosis, but for the rest of their lives. That can be any number of years.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I welcome the witnesses. They do really good work through their services. How many centres are there in Dublin at this time?

Mr. Conor O'Leary:

ARC has three sites in Dublin.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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There are three in Dublin. There are 22 in the State. You could argue for double, if not triple, that number of centres in the State to cater for people who want to use their services.

Mr. Conor O'Leary:

A better model might focus on the existing centres, which have been in place for many years. My own centre, Purple House, has been in place for 35 years. They have grown and developed over those long years so, rather than new centres cropping up, a better model might be for the existing centres to be supported to reach out to those areas not currently served.

Ms Gemma Fort:

Perhaps Mr. Conroy might like to talk about the number of people accessing services.

Mr. John Conroy:

Absolutely. Some 250 new clients enter our services across the country every week. This year, there are 16 full members of the alliance and ten applicant members so we represent 26 centres today. There are also other support groups reaching out to different communities. We have a footprint in every county in Ireland. We are certainly reaching out to every county. As I have said, 250 clients come to us every single week and, every week, 2,000 support hours are provided across the country so our impact across the country is very significant. What makes us unique is the optimal response times and that we are able to respond. If 250 people were entering another service, they might sit on a waiting list for six months. In the cancer support community, we try to triage people within five days. They have a support plan built around them immediately so that they can access services very quickly. Usually, people come in quite acutely distressed having been newly diagnosed. It is very important to us to react to that. Without an appropriate funding model, we may not be placed to meet those continuing needs.

In the case of Dóchas, we saw an 81% increase in new clients last year and a 103% increase the year before that. We are in a unique situation in that we moved from a part-time to a full-time service but every centre is seeing an increase. We are not seeing the number of clients walking through our doors slowing down. It is only increasing. The statistics suggest that cancer diagnoses are going to double by 2045. That means that our centres are only going to continue to get busier. We are also seeing the demographic profile of clients changing. We see people who have been rediagnosed or who have been given a further diagnosis of metastatic cancer. They are coming back into our services. There is a lot of re-engagement. It poses challenges across the board for us. We are rising to the challenges but it is getting more difficult.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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It seems extraordinary that the centres' funding model is reliant on charity. We all know that, to generate the €8 million necessary to cover the costs, an enormous amount of time must go into fundraising. An amazing amount of time goes into that. That time could be spent enriching services. It just seems extraordinary. I hope they can get the funding they need in the budget.

Ms Gemma Fort:

One of the key things for each of our centres is their community-based nature. This morning, we met the Minister, Deputy Foley, in whose constituency I live. To quote her, it is very much for the community, by the community and in the community. It is a measure of how trusted each of the centres is that the community has supported us. The goodwill has been there as regards volunteers. Every family in every community has been touched by cancer. All of us here have had some engagement in some shape or form. There is a recognition that supports are needed but the supports need to be supported. We have to build on that. We are not looking for everything to be covered. We are saying that we are meeting this challenge but that we need help and what we are doing to be matched by an investment from Government to keep us going. If we do not get that, our development and sustainability into the future will not be supported.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I will ask a final question because I am running out of time. Do the centres provide end-of-life counselling when people are in the latter stages of their illness?

Ms Gemma Fort:

There is a level of that. We are dealing with palliative cases.

Mr. Richard Flaherty:

We also provide bereavement counselling for family members who have lost someone.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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That is equally important.

Mr. Richard Flaherty:

It is equally important. It is not just the cancer patient who accesses our services. After someone has passed away, the family members are still psychologically distressed. We provide ongoing support for them. A broad range of people use and need our services.

Bernard Durkan (Kildare North, Fine Gael)
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I welcome our guests and congratulate them on the tremendous work they are doing all over the country, including in my own constituency at the Little Way Cancer Support Centre in Clane, County Kildare, which has done tremendous work over the years. The secret to the centres' success is that they are community-based and that they arose out of necessity. From the beginning, it was recognised by those who would start the voluntary organisations that there was a need for counselling services, a need to respond to the cries of help from people who were diagnosed at an early stage and a need for professional services, which is what the Little Way Cancer Support Centre has provided. As has been said, it is a difficult thing to manage all of these services on the basis of voluntary contributions but voluntary contributions can help an association with year-on-year support, whether large or small.

I am also concerned about the number of instances of cancer in young people that I see from casual observation. I presume it is as a result of Covid - obviously it is - but it is frightening. The need for the services is so much greater than it was, especially among young women. A huge number of young women seem to be diagnosed with and affected by cancer and, unfortunately, passing on as a result of it. The need that was originally and initially there is greater now than it was, as is the need for voluntary services, which are a soft form of support to people who find themselves in a vulnerable position at a given time. The centres are to be congratulated for that and for carrying on the service through thick and thin in the recent past.

My query relates to the €5 million from now on that was talked about. Presumably, the centres will look for that to be an annual event, with increments, as time goes by because, as I see it, the need will increase. It has been suggested that there will be a drop in cancer cases in the coming years. Be that as it may, right now, there is a very serious demand that needs to be met. The centres would be well supported in seeking assistance in line with the demand as it now presents itself. As I said, that is based on casual observation of the number of people I know with cancer. We all know the number of people who are passing on and dying of cancer, which obviously arises from Covid. The frightening part of it is the number of young people, and young women in particular, who have it. I ask that particular cognisance be taken of that aspect of the demand as we move on into the future. Do the centres have plans to recognise that and to expand the services they have available?

Mr. John Conroy:

I will talk about our centre. We continuously review services on a year-to-year basis. Last year, we recognised that we were not meeting the needs of a cohort of the population, and this was just for our centre, which was children and young adolescents. We expanded our services in December 2023 to meet that need because it was something we were seeing, exactly as the Deputy said. We are also uniquely placed in that we are supporting children who may have a parent or sibling who has a diagnosis. We are able to provide a number of programmes, such as the children's lives include moments of bravery, CLIMB, programme, where children have an adult with a diagnosis, or play therapy as well. It is definitely a part of our service that we are seeing a growing demand. We are trying to meet that demand.

Mr. Richard Flaherty:

The Deputy's casual observation is actually quite accurate. I was in the support centre in Galway talking to and having a coffee with one of the oncology nurses there. She referenced the number of young people who have come to the service with cancer, and who are presenting quite late at stage 4, which was quite surprising and shocking to me. I do not know whether that is a legacy going back to Covid and late diagnosis, but it is seemingly a significant increase. That is a challenge we need to meet because the more complex cases, as referenced, need more comprehensive care and more resources. We are happy to provide that.

The Deputy is right. If a person comes in to us young, and it is to be hoped he or she will get over cancer, that individual will need years of care and support. As we just have once-off funding from the Government, we are not in a position to plan accordingly. The Deputy is right. We were delighted with the €3 million last year but we see it as just a first step in putting consolidated funding in place so we can all plan for what is coming down the tracks in terms of numbers, profiling, late diagnosis and what is coming down from Covid. It is critical for our sector.

Ms Gemma Fort:

I will add to that point. When young women come in who may have young families, the whole family needs support. When cancer comes in the door of a home, it casts a shadow on everyone there. We are all recognising that through the provision of services for children. A number of our centres are providing play therapy for children whose mothers or fathers are going through cancer. At present, we are delivering a programme for young people who have lost their fathers to cancer and are all between eight and 12 years of age. They are very young. That is a very tender age and vulnerable time to lose a parent. We are able to provide services for a mother coming in who may have breast cancer, but we then find that women are living with metastatic breast cancer, and their health needs and psychosocial needs change as they get older. We are supporting them and could also be supporting their partners through counselling, in addition to the children. It is a whole family approach.

It is all free of charge because the impact of cancer on the financial situation of a family is massive. To be able to get services free of charge is a weight off their shoulders. If they know they can get play therapy for their children, counselling for themselves, or things like wig fitting, or bra and prosthesis fitting free of charge, that is a huge weight off. We cannot do that without support.

Mr. Conor O'Leary:

To add to Ms Fort's point, those services are not available anywhere else. Those families are alone at home in isolation. That can lead to further mental health conditions, including depression and anxiety, which will impact on them. We know no bounds, and do not need to say it, but we know the impact that is having on us as a country.

Seán Kyne (Fine Gael)
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Is there a standard client? Is it across all sexes? Are women more likely to avail of services than men? Are younger people more likely to avail of them? Where children are involved, are parents more likely to avail of services? Is there a standard?

Ms Gemma Fort:

It goes across all age demographics and all of society. Some 75% of people attending are women but we are seeing more men. Different centres have different programmes. We have a men's group, for example, virtually all of whom have had prostate cancer. We have a women's group virtually all of whom are experiencing breast cancer. Breast cancer and prostate cancer seem to be the two most prevalent, but we are seeing ovarian, pancreatic and oesophageal cancer. I looked at our intake for May yesterday. We have somebody as young as 29 on our books at present who has just registered. We have somebody aged 40 with pancreatic cancer and another person aged around 72 with throat cancer. It is every cancer and every age range but it is predominantly women who will engage more quickly than men.

Seán Kyne (Fine Gael)
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Mr. Flaherty mentioned the young mother who came straight from BreastCheck to the services. Is that initial contact the most important? How long does contact last? If somebody is going through chemotherapy or radiotherapy, is he or she less likely to be physically able to reach out? Is it after that person has finished treatment that he or she needs more supports? How would it-----

Mr. Richard Flaherty:

It is at every stage and it depends on the person. The good thing about the story I told is that person was referred by staff at BreastCheck who were aware of our services. We link in very closely with the BreastCheck hospital. That person needed our support at that time. There are people who when they get a cancer diagnosis will go through their treatment and brave it out. They think they can get through it but they have a fear of recurrence. They may come through their cancer but it is the fear of recurrence. They are not able to get their lives back to what they were before the diagnosis and they should be able to. They will access support then. People access support at various stages. We provide support during and after treatment and beyond. People decide themselves when they need it. The most important thing is all the staff and people know we are there, on a drop-in basis, when they want services.

To go back to the point about men, thankfully, society has changed. We opened our centre 15 years ago. There were very few men. We could not even get male volunteers to work in the centre. We have seen a shift in that. We have a men's support group of 17 or 18 men that meets every Friday morning. We would not have got those numbers ten years ago. It has thankfully changed. More men seek help when they need it as they go through their treatment. They are able to talk among themselves as well and provide that mutual support, in addition to the support they get from professionals.

People come at different stages, genders and ages. As I said, it is family members as well. One in four people who use our centre are people who are not directly diagnosed with cancer themselves. They have a brother, sister, mother or father who has cancer and support for them is as important as anything as well.

Mr. Conor O'Leary:

To add, the sector is a very person-centred sector. The services have been very much client-led. Over the years, as Mr. Flaherty said, the demographics may have changed slightly, but the beauty of the sector is that we are able to adapt the services to meet the needs of the client at a particular time. We are quite a lean sector to be able to do that. Oftentimes, a big group of clients will identify a need or a needs assessment will be done, either by the NCCP or by the centres themselves for a particular type of service for a particular cohort of patients. Once the due diligence and clinical governance is done around that, oftentimes that is how many services have come into existence, such as support groups or various survivorship programmes. They have all been client-led. As a sector, we really listen to the patient and we provide what they need and what they want at whatever stage they are presenting at.

Ms Gemma Fort:

It does appear that when people are involved in having surgery and their treatment, there is a very structured nature to that because they have appointments and follow-up checks. It is when that active treatment ends that they can often feel very vulnerable because that suddenly is not there as a point of reassurance or contact. That is when we do see that people look for other support within the community. One of the things we pride ourselves on is our connections within our local communities because people come to us for particular support, but if we see there is a more appropriate service, we try to refer them on so that they are connected within their community. We do a lot of work with family resource centres. We link in with the healthcare professionals in palliative care or oncology. They refer to us, but equally, if someone comes in to us and we feel there may be an issue for them health-wise, we would refer them back to their oncology nurse because we do not provide medical treatment. We very much complement the medical model. There is a recognition that both of us have an important role to play in somebody's cancer journey.

Seán Crowe (Dublin South West, Sinn Fein)
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I thank the witnesses. Senator Hoey wishes to speak.

Annie Hoey (Labour)
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I thank everyone for their presentations and all the work they do. As someone whose family availed of community-based supports, including myself, the work they do to support people is not unrecognised. I do not have many questions, but I am very interested in listening. Ms Fort spoke about people coming in a little bit later on or after their treatment. Would many people approach for support a couple of years after they have been diagnosed, either because the cancer journey can be quite long or maybe their journey has ended and they are in remission? Would anyone come to the community cancer centres for support? I am interested to hear, as I am a big believer in screening. Obviously, we have got some great uptake. I believe our we are third in the EU for breast cancer. We have quite a high uptake in screening. I would like to see screening rolled out in other areas as well, particularly for lung cancer, because were we screening for it, my dad would still be here. Would the witnesses have any thoughts on that or is that something that comes up, even in conversation? Obviously, the witnesses are at the coalface and maybe people are not hypothesising about what services could or should be. I wonder whether that is something that comes up, that there is an awareness that there could be additional screening for certain kinds of cancers, but that we just not have them here yet. Does that ever come up in conversations the witnesses have with people?

Mr. Conor O'Leary:

On the Senator's first point, cancer is a trauma on the patient their immediate family. The question is: when does that trauma become too severe for the patient to handle it themselves and there is a person-by-person factor? We find that it could be something else, such as additional needs, or they may have a child with additional needs that may trigger something at a certain point. The cancer may have been in their lives previously, but that trauma is still within them and perhaps still in their subconscious that they did not realise. Something else may bring them to the door of a cancer support centre. There is no set time but our services are always open. There is no time limit for somebody to avail of the services whenever they need us.

Mr. John Conroy:

We certainly do not limit time either as to when somebody can engage with us. One of the services we provide is manual emphatic drainage therapy, which is for people who may develop lymphedema due to a surgery related to a cancer diagnosis. Lymphedema can present at any stage. Somebody two, three, four or five years post-surgery may start to develop lymphedema and then they may come into our services. What we find with people who do come in four or five years later is that they may not have engaged with services and when they walk in they realise they have never addressed any of the trauma around their original diagnosis. Subsequently, they start to fall into other parts of our services. That is really important, that people know they can address this at any stage because what we find is that people go into the motion of getting through these appointments, and they have so many hospital appointments, six weeks of radiotherapy and six months of chemotherapy. Day by day, their routine is thrown out of kilter completely. They may not engage and then once they are through it, they may not want to go back to it and feel like they need to start moving on. Then they realise the trauma is there and that is where we pick up those pieces and can come in and help support. It is important that people know there is no time limit on our services.

Ms Gemma Fort:

To address the Senator's point on screening, all of our centres would promote awareness about the various cancer awareness weeks, bowel screening, BreastCheck, cervical smear week and all of that, for example. That is really important, as is early detection. Part of our intake assessment for new clients is that if they mention symptoms, we would always say they need to go back to their oncologist because they need to be their own advocate for their own health. Our clinical staff would feed into networks whereby they would identify new patterns emerging. Screening is always vital and we have seen that with the success of various programmes. We can only feed into that in terms of identification but I do not believe we would have a role in determining what those programmes would be. I hope that answers the question.

Annie Hoey (Labour)
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It is an area I am interested in. I want to see screening for many more cancers rolled out and I know there are trials and plans to see whether it works in certain socioeconomic areas. I would like to see those rolled out because for certain cancers, particularly lung cancer, the evidence in the UK shows that it could catch that cancer much earlier. It is very much a silent cancer. Obviously, I have a very personal interest in that one. I want Ireland to start screening for other cancers. It is great the witnesses have highlighted that people can come at a later date and acknowledge their trauma because it is a gruelling experience and it does not have to be their experience of cancer at that exact moment. I thank the witnesses.

Seán Crowe (Dublin South West, Sinn Fein)
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I have a few points. First, the point was made about the importance of the centres themselves and the fact there are only a handful around the country, which highlights the fact we need more of these type of centres. The main point the Alliance of Community Cancer Support Centres made in its presentation this morning is that there is a reliance. The State is relying on charities and on the voluntary sector, but there needs to be a certainty regarding the various centres.

I am aware of the centre in Tallaght. I do not think it is affiliated with the witnesses' centres, the Tallaght support group, and I would have been aware of it over the years. With regard to the likes of these groups, Senator Kyne asked a question about how people could get in touch. It is based at Tallaght University Hospital, and it used to be based in Tallaght village. You would see, when you are going in for treatment, that there is a sign there and the support is there, who to contact and that.

The most important point for anyone listening at home is that there is life with cancer and there is life after cancer. The witnesses’ figures say that there are 50%-plus survival rates from ten years ago. That reflects the fact that there is so much groundbreaking work going on in the area. We would have had cancer groups in and they would have been quite critical that some of the new drugs that have become available that have not been passed here. I think there have been something like 23 new drugs in the past two years, which sounds great, but you are talking in terms of the amount of drugs that are out there that can be life-changing for people.

I have had cancer twice myself so I have been through the system. I know what it is like to be told that you have cancer, and to be told a second time that you have it, and the challenges you face. I have seen grown men and women cry going in for treatment, terrified of the idea of , say, getting the likes of radiotherapy and so on. Given the number of people who have approached me, and again, I am reflecting on what is probably happening in the witnesses' own centres, to talk to someone who has had it and who has been through it is really positive. I presume the common denominator from the witnesses' own centres is that there are people who have had it themselves or their family members have had it. The positive message is that there are supports and there is help there.

It is so overwhelming when you are told, with the amount of information you are given. There are things that you are supposed to do. Everyone is asked at some stage, if they are going in for, say, chemotherapy, what medication they are on. They will probably ask the person and the person will look blankly at them. The partner will ask. A simple thing can be to take a photograph of the medication you have. It can be that simple. There are all of those things. If people engage with the centres, there are people who have been through it and there are people who know the system. It is simple things like if you are asked to change padding or a bandage, or if you are someone who has never used an incontinence pad. You might be embarrassed to ask someone else but there are supports there, and they are simple, everyday things people can learn to do. If you can talk to someone who has done it or been through it, I think it is much more simpler.

I do not really have a huge number of questions. The funding issue clearly does not make sense. If we are talking about, as a State, our medical services relying on voluntary organisations, we have to fund them. One of the concerns that some organisations have come to us about is the new gambling regulation. I do not know if that is a concern for the witnesses. If it is a certain amount of money or if you are raffling a car, for instance, that is going to be a challenge under the new regulation. I understand the problems with addiction and so on but we need to be much more inventive with regard to how we can support organisations like those represented here. The witnesses are not the only ones who come in here. We constantly have organisations that will say to us that there is a plan in place but they do not have the funding or supports.

Is there anything the witnesses would ask us as a committee, in the next couple of minutes that we have? What is their final ask on this? Again, we do not have much powers but we will have the Minister, the HSE and the Department in on this. The witnesses have outlined their story. They might explain to us exactly what psychosocial support is, not necessarily for me or the members but maybe for the people listening at home, and the types of services. If I walk into one of their services, what exactly will happen when they meet someone on the desk? Will the witnesses talk us through the ABC of it? I presume it is common across all of their organisations.

Mr. Conor O'Leary:

"Psychosocial" is a combination of two words. The first is "psycho", which refers to "psychological" and everything to do with your head and emotional well-being. The "social" aspect is that it is a community. You are meeting other cancer survivors and other people in that group setting. It is not all group settings. We have individual services as well. It is that community-based aspect. The Cathaoirleach mentioned how important it is to speak to someone else who had gone through cancer. That is what we find. We upskill volunteers. A client would come in, avail of the services, and then when they recover and no longer use the services and have passed the period of two years, they are welcome to come back as a volunteer. They would then be upskilled. They would go on various training programmes. For example, one survivorship programme a lot of the centres provide is the cancer thriving and surviving programme, which is run by the NCCP. The facilitators on that programme include someone with lived experience, which can be a cancer survivor or a family member of a cancer survivor, and the other is a trained professional, for example, a counsellor, therapist or somebody with a professional qualification.

When people first ring the doorbell, it is a really huge thing for anyone to do. Oftentimes, when people come to Purple House, they say that this has been fifth time they have come to try to ring the doorbell and they bottled it every time because it is such a huge thing to do. That first step is so important for people. That is why it is really important that the first person a client meets when they come into a cancer support centre is sympathetic, has empathy and is very aware of how important that first step is. It is not easy to reach out for help, especially if in your private life you are of a certain standing or have a particular role. When you have to put your hand up and say you need help now for this, that is a really big thing.

What typically happens then is there is an intake, where basically an assessment is done. A trained volunteer or member of staff will sit down with the person and hear their story and exactly why they have come to the cancer support centre. A needs assessment is then done at that intake where we find out through that dialogue if they need counselling, bereavement support, hospital transport or something for the children, and some sort of support around that. Then what typically happens is the suite of services is outlined to the client. A client can avail of any of those services. For example, they may come in to a centre like ourselves and receive counselling in the morning. Then in the afternoon they may go down to our cancer rehab gym and receive physiotherapy. They may then spend time in the coffee dock meeting other people who have had similar experiences. They can spend a period of time there availing of any services that they feel are beneficial to them.

Mr. John Conroy:

What is important for us here is that the voice of the client is heard in all of this. We are here to advocate for funding for our centres, and we are providing the supports for the client. They are central to everything we do. If the committee does not mind, I just want to read out a couple of testimonials with regard to clients coming to our centres because I think it is important that their stories are heard:

My cancer diagnosis affected every aspect of my life. My work, my physicality, my home-life, my plans.

[...]

Ironically, I coped much better with the physical changes than the mental and emotional ones. The biggest loss was any sense of control. I had to let go

[...]

During my chemotherapy, I become so unwell in every sense. I was so weak from the drugs that I went to my Oncologist after the fourth round and told her I simply couldn't go on. I wanted to quit, not something I do easily. She immediately suggest counselling at ARC for both myself and my husband. I don't know why I hadn't thought of it myself, maybe because I thought this was for other people, preferring to cope privately but miserably failing.

Through several sessions I was given the tools to cope, to separate myself from what the drugs were doing, to rationalise that this wasn't me, but the drugs affecting me. My husband also got counselling, finding a place where he could express himself openly and feel very safe in doing so.

That is from a client who was engaging in services with ARC cancer support centres in Dublin. A client of my own centre states:

I have been attending Dóchas Offaly Cancer Support over the last 19 years in various capacities. I was a volunteer for a long time with Dóchas and loved my time as a volunteer. I was diagnosed with Breast Cancer in 2005, and Metastatic Breast Cancer in 2016.

For me personally, Dóchas Offaly Cancer Support Group has always been a lifeline, somewhere I could speak openly and honestly about my condition, my hopes and my fears as my disease progressed. I appreciate the treatments I receive; they make me feel better like nothing else can as I struggle to manage the deterioration in my own health as my cancer progresses.

Nobody else can understand how it feels to be in this position as much as John, the service manager, and his dedicated staff can. Facing the hospital visits, the scans, the agonising wait for results and then dealing with the prognosis is not something we can manage alone no matter how kind and loving those close to us are.

Dóchas is carrying me through, they immeasurably improve the quality of my life through the terrifying progression of my Cancer. The emotional support I receive in Dóchas, is just as important to me as the drugs I’m on to extend my life.

However, it frustrates me to see ... [John] swamped in applications for grant funding, spending many hours fighting to keep Dóchas’ doors open to provide the very invaluable support to which I refer to, to a lot more people like me. Dóchas is one of the smaller centres in Ireland and John has a huge remit. To see the work he puts in to ensure people in a similar situation to me receive the supports I do is frustrating knowing that such a caring, compassionate and empathetic [team] should be afforded more time to be present with the clients.

My quality of life is made bearable through the specific and invaluable psycho-social supports offered by Cancer Support Centres, and in my opinion it is a regrettable misuse of ... time that John and ... [other centres] have to repeatedly be taken away from providing that care in order to fundraise and apply for grants to maintain an open doorway ...

My personal wish is that this would change, that Government would recognise how valuable the service is that Dóchas [and all other cancer support centres throughout the country] provides and that funding would be made available to ease the stress of running a Cancer Support Centre and allow ... [all managers] to concentrate 100% on making all our Cancer journeys more manageable.

That is from one of our clients in Dóchas Offaly Cancer Support Group. It is important to bring it back to why we are doing this. We are doing it for the client. That is why we are here today.

Seán Crowe (Dublin South West, Sinn Fein)
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I thank the witnesses for coming in. On behalf of the committee, I thank them and all their volunteers for the work they carry out day in, day out. I thank them for engaging with the committee on the challenges facing community-based cancer support services in the context of the national cancer strategy. As a committee, we will continue to monitor this matter and we will be doing a report. We will be making recommendations on the back of today's meeting. I again thank the witnesses for coming in. I hope they found it worthwhile. For anyone who is listening at home, there is support out there. Just reach out and pick up the phone. Your centres are open and you will always be welcome to drop in.

Ms Gemma Fort:

On behalf of the Alliance of Community Cancer Support Centres, I thank the committee for having us. We really appreciate the time today. I wish to mention the many volunteers involved in our centres who have survived cancer. As one of them put it, she is involved as a volunteer to celebrate her survival. There is a huge amount of contribution in the community from people who have used the services and who see the value in them. I wish to bring their voice to that today. They are doing everything they can to ensure those services are there for people like them. It is all about them. I thank the committee for giving us the time and listening to us today. We very much appreciate it.

Seán Crowe (Dublin South West, Sinn Fein)
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I thank Ms Fort for ending on that positive note.