Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome, from Carers NI, Richard Meade, devolved nations director, and Áine Magee, public affairs and media manager. I also welcome, from the Rural Community Network, Kate Clifford, director, and Samantha Gallagher, policy and public affairs officer. I remind members and witnesses that we have 45 minutes for the evidence session. We have in front of us your papers and responses to the consultation, which are useful. If you want to add anything to those, you can do so.

Ms Áine Magee (Carers NI): I am happy to go first. The witnesses in the previous session made some really valuable points, particularly about the ideas already being in place but there not being the resources to take them forward. For example, the just-in-case boxes and the advanced care planning strategy, which is sitting on a shelf despite the huge amount of work that went into it. I have a pile of remarks to make, but one of the most striking things is that in the research and in the contributions so far, the role of carers has not been mentioned or highlighted.

Palliative care is something that most of us will need when we approach the end of our lives, and dying is a universal experience. Unpaid carers are critical in the support of someone who is living with a terminal illness or is approaching the end of their life. Research has shown that the key factor in supporting someone with a terminal illness so that they are cared for at home and can die there, if that is their choice, is to have a live-in, unpaid carer. Often, that carer is a family member. The Assembly research that I had access to indicated that 47% of individuals die in a hospital and 38% die at home. The figure for deaths at home could be higher, if the resources were there to enable that.

We have to understand that we have an ageing, sicker population. The four Chief Medical Officers (CMOs), including ours, have indicated that we will get older and sicker, so we will need more palliative care and more support in the community. In parallel with that, we need to design a strategy for supporting carers. How do we support the carer who is living at home and trying to support the person who is ill? The feedback that we get is that carers fill the gaps in the statutory support provided by Health and Social Care (HSC) services, often for many hours and nights or seven days a week.

Carers NI reached out to its members. There are 222,000 unpaid carers in Northern Ireland. We are a membership body, and we asked carers for feedback, some of which was heartbreaking. One of the key things is the inequity across the region. It is a postcode lottery. From the feedback that we received, I know that — I am happy to be corrected on this — as part of the Southern Health and Social Care Trust's out-of-hours service, there is one Marie Curie nurse. If two people require the administration of medicine, whom do you go to? Who deserves that care more? Who deserves that medicine and pain management more? One person whose husband died recently — last month, in fact — said that the care was so disparate and unscheduled that, at bedtime, when she needed that support most, it often was not there. Her husband was quite heavy, and she was unable to lift or wash him, so he spent many's the night on the floor, because she just could not lift him. A lot of personal care is required, particularly when you are dealing with a protracted period of end-of-life care.

It is incumbent on us to indicate that carers in Northern Ireland are not doing well. We know that they struggle with their mental and physical health and that they experience poverty more than those who do not have caring responsibilities. It is important to say that carers experience death and dying in a very intense way. Those who care for someone who is going through dementia, Parkinson's or Alzheimer's say goodbye multiple times and in multiple ways and grieve for a person whom they lost a long time ago and who has changed into someone a little different. There is a grief process when you care for someone who is unwell, so support for carers needs to be in place in the pre-bereavement period, the bereavement period and the post-bereavement period.

We need to support carers' needs too, as we have this inquiry into palliative care and look at what a palliative care strategy for Northern Ireland could look like. We have drawn up a paper that Committee members will hopefully have received that covers 12 recommendations, including, at policy level, the need for us to make carers the central focus of any palliative care strategy; to support their mental health needs; and to put in place measures to prevent the cliff edge of eight weeks for carer's allowance. When a person dies, their carer's carer's allowance stops after eight weeks. We would like to see that period extended to at least six months.

There also needs to be a focus on employer support, which is about how an employer can facilitate an employee who is a carer and is dealing with somebody who requires palliative care to provide that care, particularly in the home. There needs to be an awareness regionally of what palliative care means, because a lot of people think that it refers to just the two or three weeks at the end of someone's life. It can be for a much longer period, and it is not needed just by elderly people. We need standardisation of out-of-hours care in particular; a gendered approach, because nearly 60% of carers in Northern Ireland are women; and, if we are talking about having a "Shift left" approach, to support and invest in the community and voluntary services that enable care to take place.

The other recommendations include one on carers' health. Carers need to be singled out, because they put themselves and their needs to one side all the time and are exhausted. There also needs to be pre-bereavement, bereavement and post-bereavement support. Finally, we need investment from the Northern Ireland Executive.

From the beginning of the conversation, although the person receiving palliative care needs to be front and centre, their carer needs to be considered just as much. They need to be recognised as a person who has significant needs of their own and should be treated as an equal partner in the care of the terminally ill person. We only get one chance to get it right at the end of life, so our palliative care strategy must embed that in its approach. We welcome the fact that the Programme for Government refers to a focus on death and dying. It is crucial that that involves unpaid carers: there can be no strategy without them.

Mr Richard Meade (Carers NI): We need to think about the consequences of an unpaid carer not getting the support that they need. If an unpaid carer does not get the necessary support, they quickly become overwhelmed and hit crisis point. That can lead to a range of unhelpful outcomes, including an increased risk of unplanned hospital admission, accident and emergency (A&E) attendance, calls for ambulances and failures to discharge.

There is also the impact on the carers themselves. It is not uncommon for the carer to have a severe health episode and end up being admitted to hospital. That has consequences for the experience. Again, we have only one chance to get it right. A person may be keen to be cared for at home and, ultimately, to die at home. A failure in the support for their unpaid carer may lead to a breakdown that means that the cared-for person dies in a hospital, which is where they did not want to be. In such circumstances, the person caring for them, who is often a family member, may not even be able to be there because they are so unwell. Such a scenario has huge human consequences. It adds to the complexity of the grief and the bereavement that the unpaid carer might experience, which can have long-term implications after the person has died. Economically, it puts increased pressure on acute settings because of unplanned hospital admissions and accident and emergency attendance that, perhaps, would not need to happen if the unpaid carer were getting the support that they needed to continue to care for the person approaching the end of their life. There are economic costs too.

It is therefore crucial that unpaid carers are front and centre when we talk about palliative and end-of-life care. In the last 12 or six months of life, taking account of the number of people who die in hospital, the vast majority of care is delivered in community settings, often at home. It is the unpaid carer who provides that care most of the time. It is the unpaid carers who are there 24 hours a day, seven days a week. Services come in around them, but they provide the support. They are the linchpins for getting it right at the end of life.

Ms Kate Clifford (Rural Community Network): My colleague and I represent the Rural Community Network in Northern Ireland. We are not experts in healthcare — absolutely not — and we are certainly not experts in palliative care. We are experts in rural access and equality of access to services. In our paper, you will see a response on access to services and the challenges in that area.

There are difficulties due to the limited access to public transport in Northern Ireland, which speaks exactly to what was said by our Carers NI colleagues and the witnesses in the previous session. When you move out of the main towns and cities, access to care and services becomes really challenging for people. We look at the added burden. If your only hospice is the Foyle Hospice, the Charis Cancer Care centre in mid-Ulster or the Northern Ireland Hospice, access to public transport to get there is really difficult for people who live further away or outside the main towns and cities. The cost is extortionate. Trying to get people onto public transport also becomes problematic, because they are vulnerable. They are receiving end-of-life care or have serious conditions, so putting them onto public transport is difficult anyway. People rely on community transport schemes, which are only partially publicly resourced, or on family members or social car drivers to take them to appointments in hospitals.

The big issues for us are the reduction in the number of bus routes and the infrequent services. According to Marie Curie, many patients in rural areas experience delays in accessing their healthcare but then forgo their appointments. Do people who have cancer or are in need of palliative care have worse outcomes because they lack access to transport? Macmillan Cancer Support is doing work on that, and Marie Curie has begun looking at the outcomes for cancer patients in rural areas. The issue is not just that those people present later and are, therefore, more acutely unwell when they do: accessing care and maintaining appointments becomes really challenging if that person is unable to drive or take themselves to their hospital appointments.

Travel burdens deter timely access to end-of-life care, complicate visits for families and carers and make it really expensive for families and carers. Those are big issues for us. We are engaging with a student whose mother is in Altnagelvin Hospital. They are having to hire an Airbnb for a week while she undergoes her treatment because they want to be on hand. The burden of travelling daily from Enniskillen to Derry to be on hand for her mother is too much. There is no way that she could do it: she is elderly herself.

Workforce shortages are a huge issue for people whom we speak to regularly. Access to care and community care is a real challenge. That puts an additional burden on carers and family carers and means that there is no respite, which has ongoing implications, such as family breakdown, increased tensions and all the difficulties that lead to worse health outcomes for the entire family, not just the person who is unwell.

We have problems with access to GPs in rural areas. Our GPs are overwhelmed. Their waiting lists and patient lists are huge — much bigger than they should be. We heard about Project Echo in the previous session, which is a phenomenal response, but lots of our GPs feel isolated and vulnerable because they are the sole carer for some of their patients.

There is inequitable service distribution. Hospice services are largely concentrated in urban areas, which makes it really difficult for patients in remote and rural areas. We talked about compassionate workplaces and the idea of flexibility in the workplace to facilitate people who need to take time off to be carers. One of the biggest pressures on people, in addition to the distances that they have to travel, is their caring responsibilities. As was mentioned by my Carers NI colleague, caring responsibilities are not for two weeks; often, they are a long-term commitment. How do we build compassion in workplaces? How do we build in death literacy and media awareness of death literacy and things like DNRs? How do we encourage people to think about what happens at the end of life? There have been some really successful projects like Rural Support, which is beginning to have those conversations in the farming community, but it has not been widely looked at.

When we started to talk about palliative care, even among ourselves, we always talked about it being end-of-life care when, in fact, palliative care is lifelong condition care as well. It is about how we create awareness and have conversations around that.

As an organisation, we have huge issues with the cost-of-living crisis and how that impacts on rural communities in particular. We have socio-economically disadvantaged communities and high levels of poverty and hidden poverty in rural areas. It is harder for patients to access care. It is harder for patients to access transport, so options become expensive for people. Recently, we did a study on a member of ours who lived in Carnlough. When the local GP surgery closed, in order to get a day appointment, she would have to leave home at 9.45 am and would not be home until, I think, around 3.50 pm. The cost of taking a taxi would be around £25 plus waiting times, if a taxi were available. Taxis are not always available, because lots of taxis in rural areas are taken up doing school runs. That becomes a real issue. Family Support NI talked to us about the fact that travel costs can be claimed only for the cheapest form of transport, so costs will be paid only for the bus journey. The taxi cost will not be paid, even if the taxi is the only option for people.

There are huge complexities around people who are receiving end-of-life care and need access to advice services and support. Again, there is one opportunity to get this right, but often advice services are centralised. People do not know until it happens to them where to go to get advice on how they plan for end of life, how they do end-of-life planning and what their entitlements are. It might be the first time that anyone has ever thought about carer's allowance, any benefit or universal credit. Again, it is about how we help people to navigate that and how we do that fairly. If you live in the centre of Belfast, it is likely that, with the population concentration, you will know where to go to access that information. It is much more difficult to do that if you live in a rural community and do not know where the services are located or have never had to use them previously.

We have huge issues around digital exclusion. We understand the issue around telemedicine, but digital exclusion in rural areas relates to digital literacy, access to devices and access to reliable broadband. Again, I keep saying it — you will be sick hearing me say it, Danny — but I still have really rubbish broadband. I pay for two broadband services — one at one side of the house and one at the other — and I am not in Buckingham Palace; I do not have an east wing and a west wing. Broadband is still unreliable in many areas. In many areas, we still have not spots. There is an idea that people are connected and that, when an ambulance, carer or care support comes out, they will be able to access Encompass: that is not always the case. There are still significant numbers of not spots around Northern Ireland. Maghera town centre still has no Wi-Fi. There is no 3G or 4G in the centre of Maghera. Digital is great. When it works, it is great, but we still have inadequacy around it.

We are not against the centralisation of services; we never have been. We take the clinical and medical approach, which is that, where you concentrate people who see more people, we get better health outcomes. However, we need a network and equity of access. We need to ensure that, whatever goes in the place of centralised resources, people are not disadvantaged simply because of their geography. People cannot change their geography. We must absolutely ensure that, whatever services are put in place — whatever palliative care strategy — it must not be a postcode lottery. We want to make end-of-life care as good as possible for people in rural Belleek, as we would for people in Belfast city centre.

The final bit for us is that we have to look at the cross-border aspect. We cannot ignore the fact that the most successful model of hospice care has been the Foyle Hospice, which reaches into Donegal. Until Donegal got its own hospice set up, that service was provided on a cross-border basis. We have communities that are more logically connected to the South than to the North. That would prevent people, including our carers, from falling into really huge ill health. We need to think about cross-border solutions. Unfortunately, whatever people's politics are around the border region, we cannot deny the geography of cross-border care. We have had successful projects like Cooperation and Working Together (CAWT). The witnesses in the previous session talked about things that have worked: we have seen projects that work really well, but we have seen them fall by the wayside because they have not had consistency of funding or been mainstreamed, yet they have been proven to work and have far better health outcomes for those who have accessed them.

I will shut up now and let Samantha go.

The Chairperson (Mr McGuigan): Thank you very much for that. That has all been useful. We will go straight to members' questions.

Mrs Dillon: Thank you all for your presentations. They have been helpful. We often talk about carers as though it is always about adults and caring for adults. One element that can be forgotten is that, often, parents are caring for children and older adult children. There is another layer added where they are fearful about what will happen to their young person if they become ill. As regards Kate's presentation, that becomes much more difficult when you live in a rural area. We need to keep our focus on that.

In relation to the carers element, we might want to write to the Communities Minister or even to the Communities Committee — whichever is more suitable — to see whether the Minister has plans to further fund carers when the person whom they are caring for has passed. It is a real issue. Often, it is a household where, unfortunately, there have been two people on benefits for a long time. They have all the same bills and costs, but there is only one person left in the household.

In relation to your presentation around accessibility and transport, Kate, you are right in all of that. Do you have any suggestions for how we address some of the issues around rural palliative care and access to services not just for the patients but for the carers?

Ms Clifford: We put a couple of things in our paper to you on integrated transport solutions. With community transport, most of the journeys that they do are around health appointments. They have proven time and time again to be the lifeblood to many, particularly older people, who, for whatever reason, are not allowed to drive any more or do not have access to cars any more. Those community transport solutions are absolute diamonds in our rural communities. They get no funding from Health, yet most of their journeys are around health and well-being. There is something for me around them being resourced properly to do what they do. They have multiple solutions: not just putting a minibus on the road but the care appointment.

To highlight some of the impacts of that, during storm Éowyn recently, it was the volunteer drivers who went out and knocked on the doors of the vulnerable people. They went back to the people whom they were used to calling on and taking on trips. They were the first people to put boots on the ground and put eyeballs on the people whom they knew who were extremely vulnerable and might not have been on the NIE Networks list. That is the value of having that local knowledge. To go back to the conversation that we had recently, there will be regional solutions. There should be a regional strategy for palliative care, but, at a local level, those local projects should be stepping in and doing that work.

We talked about transport hubs at our reconfigured hospitals and subsidised travel costs for low-income patients with robust help with a healthcare cost scheme that looks not at the lowest possible price of buses but at what is most appropriate for that person. If someone has a compromised immune system because they are having MS treatment, they should not be asked to get public transport. That is ridiculous. That just puts that person back by six or eight weeks, if they end up on a bus beside someone with norovirus or COVID. The most appropriate form of transport for them is possibly to go in a taxi, where they can socially distance from other people around them. It is that help with healthcare costs that could be much more strategically thought about.

Ms Samantha Gallagher (Rural Community Network): It also needs to be rural-proofed. Universal credit is currently the passporting benefit to help with healthcare costs. A Northern Ireland Statistics and Research Agency (NISRA) report on moving from tax credits to universal credit really highlighted that the rural complexities were causing difficulties in navigating that move from legacy benefit to universal credit. There are two big things rurally. First, we tend to have larger family sizes. That is the general rule in Northern Ireland compared with the rest of the United Kingdom, but rural communities in particular have larger families again. There is a two-child limit on universal credit, and a carers element is attached to it. Secondly, there are complexities around, for example, being self-employed. Farming was the big issue in that NISRA report. If we are to look at having support through any sort of regional network, that really needs to be an overarching consideration.

Easilink and Community Transport Fermanagh, in conjunction with Derry Well Woman, were part of the scheme that we mentioned in our report. In one year, they facilitated 6,000 journeys, and, over the course of their five-year funding, they facilitated 25,000 hospital appointments. That is serious evidence of need, yet there is no funding from the Department of Health for them. That in itself is evidence of the need and the benefits.

Ms Clifford: Every rural transport journey that is achieved means a hospital appointment that is attended, as opposed to it being a "Did not attend". Again, it is about the cost of the "Did not attends" that happen because people cannot get there. Going back to our cost-benefit analysis of the economic savings, rural transport is saving a fortune for people who otherwise would not be able to get to hospital.

Mrs Dillon: Thank you both very much for that.

Chair, I suggest that we write to the Health Minister. I know that the Infrastructure Minister, Liz Kimmins, is meeting representatives from Community Transport. She raised that matter when she was Chair of the Health Committee, but she will raise it again, as it relates to her new portfolio. However, it is important that we write to the Health Minister to find out why the Department of Health is not providing some funding. I have asked that question before.

That is not all. This is where Departments can genuinely work together to overcome some of the biggest challenges in accessing healthcare for our rural communities. It is really important. That can go across all Departments, by the way. There is no reason why Education Authority (EA) buses cannot be used during the summer months when they are sitting in depots all around the country. It is madness. A lot of work could be done, but we should write to the Health Minister and ask what conversations he is having with the Infrastructure Minister and what his plans are. We need to be more definitive, rather than keeping it as broad as that, because it allows for too waffly an answer, for want of a better term. We need to get some answers not only on hospital appointments but on carers' access to the support services that they need. We should try to get some answers around that, Chair.

Mr Donnelly: Quite a lot to go through. It is amazing that there are 222,000 carers in Northern Ireland. More than a tenth of the population are carers for people, and they save the health service — I cannot remember the figure.

Ms Magee: It was £5·8 billion.

Mr Donnelly: A total of £5·8 billion a year. That is a huge amount of work that would otherwise land on the health service. Carers prevent patients from arriving at the doors of A&Es or being admitted to wards, because they keep people in their homes and as well as they can be. It is really fantastic to hear about that work. Obviously, those carers do a lot of work. I think that 44% of carers do more than 90 hours per week of caring. When we consider that a full-time job is 40 hours a week, we see that their whole lives are dedicated to caring for people. You can see how they can become strained, ill or whatever else.

Carers are obviously the most important people in those patients' lives. How is their input received in the health trusts when it comes to the likes of A&E departments, palliative care services and the Ambulance Service? Are they able to communicate well in the health trusts? Sometimes the patients cannot speak for themselves, so their carer is the main person.

Ms Magee: It is patchy.

Mr Meade: Yes. A witness in the previous session described it. There are always lots of excellent examples of good palliative care that is being carried out, but it is completely inconsistent. We see and hear a lot that sometimes there are good experiences. Carers will get their voices heard and will be part of conversations about care and discharge. They will get support packages that will even reflect what they need in terms of their support. However, we then go right to the other extreme, where carers are not recognised, they are not invited for input, they are not involved in decision-making and, particularly in relation to discharge, if someone is being discharged from hospital, they are not involved in that planning process. They are not equal partners in care. That is a hugely challenging situation that occurs time and time again. It is patchy in the sense that sometimes they might get a good bit of care — they might be involved in the discharge planning — but then they get home and the support package that is meant to be there has not materialised or is inconsistent, and subsequently they are readmitted, and the carer does not get that support.

In terms of how we rectify some of that, there is a resource and capacity issue, but, for a good palliative approach, there needs to be a focus on the cared-for person and on identifying the unpaid carer. Who is the unpaid carer or the unpaid carers? There might be more than one. That speaks to Linda's point: she particularly referenced the parent carer, who might be caring for a terminally ill child or a child with life-limiting illness. What happens if they become sick? That is part of this. You need to identify those carers, and then there needs to be a plan for the carer alongside the one for the cared-for person. In that, there needs to be an emergency plan. What happens in the eventualities where somebody becomes sick and can no longer care for the person they are looking after, whether it is a child or whoever? There is then an emergency plan that can be put into place quickly, extra support can be coming, and you will see a greater chance of that care in that home setting continuing while the carer recovers or whatever. That is a much better approach than what we see far too inconsistently at the moment.

Ms Magee: Danny, to answer your question, Carers NI undertakes a survey of carers every year. It is called the "State of caring survey". Last year, 1,200 carers responded to it. Their overwhelming response was that they are sidelined, ignored or marginalised in all of their experiences with healthcare professionals. They are under huge pressure day in and day out. There is no doubt about that. The intensity of the hours that Northern Ireland carers provide is increasing as the years go on. In 2011, we had 56,000 people who provided 50 hours or more of unpaid care every week: in 2021, that had risen to 70,000 individuals, as recorded in the 2021 census. We know that there are at least another 50,000 to 100,000 carers who have not been accounted for as a result of the pandemic, so situations have changed dramatically. They are experiencing healthcare in Northern Ireland as really challenging because of the resources that are well documented on the system.

Imagine an A&E experience or an emergency department (ED) experience and how a carer is supported. Some of it can be sympathetic and really compassionate, but some of it is really limited because there is just not the capacity to bear in mind their needs or do a carer's assessment or understand what their needs are in that time and moment. Our survey found that the number of people who have been caring for 20 years or more is in the region of 40%, so we are talking about long periods of time. When we talk about a palliative care strategy, we are talking about people who care for a couple of months in really intense end-of-life care and people who care for between five and nine years. We also have a cohort of people who care for over 20 years. All of those people need to be supported, particularly if we are dealing with life-limiting conditions and diseases.

I wish that I had the answer on transport. I know that the Irish Government unveiled their palliative care strategy last winter, in November/December 2024. They have realised the importance of making carers one of their core pillars. One of the core pillars in their strategy is that they recognise the carer as a core element of how good care is delivered to the palliative care person or the terminally ill person, but it also recognises that we need to support the wider person who supports them, because, if they are burnt out, if their cup is empty, what kicks in? I will wrap up, because I am conscious of there being other questions from members, but that is something that we have heard consistently. I have heard it on two occasions recently at Stormont at caring events: a parent of a child with learning difficulties or a life-limiting condition asking, "What happens to my child when I die?" There are many eloquent voices in that space that have been saying that for some time. I am one of them. I do not have an answer, but I wish that I did.

Provision is so difficult. There are ongoing conversations about what short-term respite means. We know about the difficulties in accessing a short-term break. Carers deserve a break. When a carer's assessment is done, all that they say is, "What would help you care? What would help to reinvigorate you to do this for another five months or 10 months or another five years or 10 years?", and the carer will say, "A break. Give me a break. I just need two days". The strategy has just been unveiled. There might be some answers in relation to what Samantha and Kate were talking about and you were querying around transportation issues.

Mr Donnelly: I totally agree. I have heard exactly that from constituents. People live longer, so you see parents who are elderly carers. The huge concern in their minds is, "What happens after I am away?". It is certainly something that we need to keep in context.

The example that you raised of Carnlough is from my constituency. I am aware of it, and I know that people in Carnlough have been very much impacted by the closure of the GP surgery in Glenarm. They now have to travel. Some have to take public transport, which is not that regular, up the coast in order to get to a GP appointment. There had been a GP funded in Carnlough for a couple of days a week, but, unfortunately, the funding was withdrawn. The service seemed to work well in the village, but, unfortunately, it was withdrawn, so all those people now have to travel up the coast. I noted that it is highlighted on the map that you sent as one of the areas where people have to travel significant distances.

We agree totally, and I just wanted to mention the cross-border work. The Committee has met the Health Committee from the South on several occasions, and we have discussed potential areas of working together. We already have children's heart surgery and the cancer centre at Altnagelvin. I think that we are also looking at perinatal mental health with the Southern Health Committee as another area on which we could work together. We certainly agree that that is a big thing that we can do.

Thank you very much for your presentation.

Ms Gallagher: I am from Fermanagh, right on the border with the Republic. The state of the roads that link Fermanagh and Tyrone to Derry/Londonderry or Belfast is poor. There are also a number of not spots: on my two-and-a-half-hour journey to Stormont today, I lost data or signal five times. Something to bear in mind when thinking about any sort of cross-border work or any sort of network around palliative care or health generally is that the quality of the roads in the North and the South really needs to be improved. People tell us that they forgo pain clinic appointments because attending those appointments causes them more pain than they experience while sitting at home. That is very telling.

Mrs Dodds: Thank you for the presentations. This is incredibly helpful. It has helped to draw out some of the issues of which you have in-depth knowledge and which we will need to take forward.

I go back to Linda's point about community transport. When the Minister announced his hospital network consultation document, he talked about the importance of improving transport. Unless I live in a parallel universe to everybody else, we have been talking about the A5 etc for donkey's years. The Minister will not have much of an impact on road networks, at least in the short term. Therefore, it will be about how community transport is funded and accessed, particularly for people in isolated rural areas. I have those places in my constituency as well. That is a really important issue in access to palliative care, access to treatment in specialist centres and access to palliative care in our community. Maybe we should look at that in significant depth on the Committee. Thank you to those who raised it. It really is such an important issue. That was not really a question, more a statement. I just wanted to remind the Committee that we should think about this significantly.

Ms Clifford: We have a real concern about the rural west in particular, where the transport options are extremely limited. We are also concerned about the north coast and the Newry and Mourne area outside of the south Armagh direction, where there are no train stations and buses are limited. We sent maps along with our presentation because we are clear that there are swathes of the country in Northern Ireland where the roads are poor, where we do not have motorways and where we do not have dual carriageways. With the end of general surgery at the South West Acute Hospital, the issue for us is that, even with the upgrade of the A5, there will be a period where parts of that road will be impassable. General emergencies will not stop during that time, so there is preparation to be done.

My mother lives in Derry city, and I live in Maghera. There were nights when, going up and down the road to Mummy over the year and a half that that road was under construction, I found myself on the unadopted road because the signage was so poor. I found myself in Limavady one night. I know the rural roads of Northern Ireland well, but I found myself being diverted and pulling in beside the Roe Valley Resort. I was thinking, "How am I here when I am heading to Maghera from Derry?"

For me, there was something around the change and upgrade that happened on that road. I wrote to several MLAs at the time to say that the road was really poorly signposted and marked out. On occasions when lights went out on the cones over weekends, you had no clue where you were on that road. That is a main arterial route. If you are now going on the A5 in an emergency situation, whether it is you driving or an ambulance driving, the roads and diversions are not clear. Once you move off what will be the A5, you are on extremely rural roads. If you are going up over Scraghy mountain, you could find yourself in any direction very quickly, if you do not know where you are going, particularly in an emergency. For us, there is a real risk around that. We absolutely 100% agree that the road needs to be upgraded. Our difficulty is with the question of what mitigations are being put in place for people who will find themselves in emergency situations.

Mrs Dodds: Thank you for that. The general point is that transport and access to transport for hospital appointments and for all of the issues that we have talked about is relevant for palliative care and for the transformation of services. We would be doing one thing and forgetting about all of those really important extras if we did not look at both together. We had a bit of conversation about that last week in the Health Committee when we talked to Tomas Adell about how that might happen. He promised to come back to us. It is an issue that we cannot let drift.

The Chairperson (Mr McGuigan): Thank you very much, Áine, Richard, Samantha and Kate. I really appreciate your taking the time not only to submit written papers, which are useful and informative, but to come before us and take our questions.