Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome from Foyle Hospice Donall Henderson, who is the chief executive; Angela McIntyre, who is the chairperson; Annmarie Casey, who is the director of nursing and clinical care; and Dr Paul McIvor, who is the medical director. Thank you very much for coming.

I begin with an apology. The day of the Committee's visit to Foyle Hospice was the second day that I was in my role as Chairperson, and, because of other diary commitments, I was not able to attend. I will hand over to you. Please make some introductory remarks, and I will then bring in Committee members to ask questions.

Mr Donall Henderson (Foyle Hospice): Thank you very much, Chair, Deputy Chair and members of the Committee. Good afternoon. First, we thank you for affording us the opportunity to contribute to this important inquiry into access to palliative care services in Northern Ireland. It is important for us to say that, this year, Foyle Hospice celebrates its 40th anniversary, so, as an organisation, we have been providing hospice and palliative care to patients since 1985, as well as offering support to their families and their carers. We therefore warmly welcome the work of the Committee for Health on ensuring that service provision is fit for purpose going forward and that it meets the needs of those in our community who are living with terminal illness.

As an independent hospice, along with colleagues in other hospices across Northern Ireland, we know that we help alleviate some of the pressures that the health service faces in general, but, primarily, Foyle Hospice's area of operation is the Western Health and Social Care Trust (WHSCT) area. We deliver our inpatient, day therapy and community services, operate a 24/7 telephone advice line and provide bereavement support for both children and adults. We currently employ 102 staff, and they are supported by 152 volunteers across a range of activities to enhance our services further. We believe that the inclusion in the Programme for Government (PFG) of a commitment to improve support for those coping with death, dying and bereavement recognises the importance and value of such services. We therefore highlight the need to focus on how palliative care services are delivered geographically so that people have equitable access to a consistently high-quality palliative care service as they need it and when they need it, irrespective of whether they live in the most densely populated postcode or in the most isolated rural location. We point out that, for some people, their local hospital or hospice is approximately 40 miles of a journey for them.

As you will know, Northern Ireland has not had a palliative care strategy since 2015. Despite an undertaking being made a number of years ago to complete a review, that has not happened to date. That is another reason that we welcome the inquiry. The significant delay, however, means that service providers are not adequately resourced to meet the need and/or deliver care in the right place or at the right time. If we have learnt anything from the pandemic, it is how the delivery of hospice and palliative care has evolved, how it is much wider than being provided in a physical building and how it is specifically tailored towards individualised holistic care.

Since 2018-19, the number of patients whom we are treating in their own homes has increased by 24%. Some 327 of our patients who are being cared for at home have required the support of our community team at weekends. In many cases, the weekend community service has been crucial to preventing a hospital admission, an ambulance call-out or an A&E visit. Although that weekend service is a pilot project and is funded by non-recurrent moneys, uptake of it has been significant.

In a Northern Ireland context, there is a need for a more streamlined and cohesive model of palliative care that supports an increasingly ageing population with complex symptoms and comorbidities. We must also take account of the growth in the number of younger people who are presenting to us having been diagnosed with a terminal illness. For example, over the past three years, the number of patients at Foyle Hospice aged 55 or younger has increased by 17%.

The non-recurrent grant funding for our weekend community service is used for some other projects that we run. Hospices are not sustainable under the current funding model, however. Statutory funding for our core services equates to approximately 40% of our total running costs. The annual uplifts to our contracts do not keep in line with inflation or the cost of living, nor do they offer us any encouragement to recruit and retain the suitable specialist staff whom we need to sustain and deliver our services in the longer term.

Among our closest neighbours, the Republic of Ireland, England and Wales respectively have been awarded funding for 100% of their core service costs, £100 million of capital funding and, just today, £5·5 million for improvements to palliative care services. Since 2019, Foyle Hospice's annual running costs have increased by £900,000 despite our best efforts to keep costs to a minimum. We rely heavily on voluntary income and charitable donations of approximately £1·8 million to bridge the gap between our statutory income and our total costs, and that is without enhancing services or introducing any new services. A substantial deficit is projected for 2025-26.

To sum up, we at Foyle Hospice, along with colleagues in other hospices, want to see the future of palliative care services become something that can be delivered collaboratively and, most importantly, in the best interests of patients, their families and their carers.

The Chairperson (Mr McGuigan): Thank you. First, I wish Foyle Hospice a happy 40th anniversary.

Mr Henderson: Thank you.

The Chairperson (Mr McGuigan): It is not surprising to hear you mention the 100% funding for core services, because that has been a recurring theme. You are saying that your funding is sustaining only 40% of your core services at the moment. If you were to get 100% funding, allowing fundraising to cover other stuff, what impact would that have on the services that you can provide?

Mr Henderson: We would know that the service would be more sustainable. Year-on-year at the moment, we are planning one-year budgets. The organisation would like to move to three- to five-year planning cycles, because that would mean that we could plan ahead and forward-plan.

We know that that level of funding is more or less secure, but nothing is certain. It is about our workforce planning and our bed spaces. We now admit patients who are more ill, have more complex issues and are closer to end of life. Whereas, pre-pandemic, we were able to support respite for families and patients, we are not seeing as much of that coming through now as we would like. If we had funding for our core services, we could look at enhancing and improving services, and introducing new services. It would maybe not be as big a burden for us to continue to provide weekend cover as well, if we knew that our core services were supported.

Dr Paul McIvor (Foyle Hospice): As Donall said, it is about consolidating those services: our inpatient unit and our home care service. Over the past few years, we have been using grant moneys and moneys that we got for just a year or a couple of years to develop services. We have had a service for speciality doctors in our home care team for the past couple of years, and they have really improved that service. We have had an outpatient service at Foyle Hospice for the past 10 years. Again, that was done using year-on-year money, so we just live from one year to the next. That is really hard for staff retention and recruitment. We now have weekend cover with our community team — there is a seven-day service covering weekends. Again, that money is probably for a couple of years or so. We start those services, such as speciality home care doctors, but they are always in doubt. If we had 100% funding, I imagine that we could develop those services and be sure that they would be there. We would be able to recruit and retain staff, and roll those services out across the trust area.

The Chairperson (Mr McGuigan): OK. You spoke, rightly, about the inequality or inequity of service and the fact that people should have the same service whether they are urban or rural. Is it just a matter of resources? What other changes could be made to ensure that people who live rurally get the same access to service?

Mr Henderson: A couple of factors affect that for us, particularly in the southern sector of the Western Trust, which is spread out geographically. We have a small team, and they can make fewer visits in a day than staff in urban areas, maybe because of access to public transport for patients and for staff, or because the roads network means longer journeys for staff to visit patients in their homes. Perhaps Annmarie can elaborate on that.

Ms Annmarie Casey (Foyle Hospice): Staff want to do more visits but are limited by how far away a patient lives. It is about equity. You might have someone who lives two miles from their base and who they could see while out on calls or on the way back. Someone who lives more rurally, however, might get only one visit a week because you try to work up what is best, so it is not an equal service. Staff then feel that they are letting down patients just because they do not live in the right postcode area.

Mr Henderson: There is a quantitative and qualitative aspect to it. You try to see a certain number of patients in a day, but, in order to get through all those visits, you may condense the time that you spend with patients when they need a little more time.

The Chairperson (Mr McGuigan): Fair enough.

Mr Robinson: It is good to see you again. Thank you for coming and for everything that you do. I want to talk about the funding model, which you touched on. What is the shortfall?

Mr Henderson: For the current financial year, it is £1·8 million, and we are looking at a deficit of approximately £600,000 or £700,000. In saying that, we are conscious of how we budget. We had a better year than expected in the last financial year, but we are usually very conservative because voluntary income and charitable donations are so unpredictable. We factor in a worst-case scenario, and we are always hopeful that it will not be as bad as we expected, but there are so many variables with voluntary income.

Mr Robinson: Donall, what outcomes do you predict if the funding model does not change?

Mr Henderson: We would be at risk of having to look at our services. Which service would we look at first? We would have to look at throughput. Ultimately, the impact would be that the patients and families would suffer. If we could not balance the books, it would affect the community's trust. If the community see that we are not able to make ends meet, will they continue to support us through donations and fundraising activities and events?

Mr Robinson: Can you tell us a little bit about Encompass? Are you being left behind in the roll-out of Encompass across the Province?

Mr Henderson: It has been a long process. Paul probably has a better handle on Encompass than I do. It predates my time at the hospice. I started working at the hospice in 2014, and I know that there has been a push to get IT systems and electronic care records in place from well before then. We thought that we would get across the line a couple of times with different types of IT systems. It goes back to working together to make sure that everything is streamlined, so that we have access to the patient information that we need.

Dr McIvor: I agree with that, Donall. It is about our hospice services being more integrated with the mainline services — for want of a better term — to make palliative care services a core service. We all see the same patients — the trust's patients — so having equal access to the IT systems and training sessions would be helpful. Encompass is going live in the Western Trust in May, but there is no word about when the hospices will be part of it. We have read-only access to Encompass through Epic. I do not know how things will turn out, but I worry about the flow of information.

Communication is so important across the health service but particularly in palliative care. We must share the information across all the services involved in a patient's journey. Across the region, we see fragmented delivery: from one area to the next, palliative care services can vary. It is important to bring all that together — we could have a palliative care directory of services or something like that — to share the information. If a person does not know who to contact, that can be a barrier to access. Then, when they do make contact and meet the initial health professional, they want to be sure that their information will be shared with the other health professionals who it needs to go to. When that does not happen, it can be very disappointing and there can be a very bad outcome for the patient.

Mr Robinson: I am conscious that a number of members want to contribute today. Thank you. We value your work.

Mr Donnelly: Thanks again for facilitating our visit. Alan and I went to the hospice, and it was informative. It was great to see your place, and we learned a lot. It is a lovely environment. I am impressed with the weekend service, and, as Donall mentioned, the impact that it has on the statutory services. It means fewer GP call-outs, fewer visits to A&E and fewer calls to the Northern Ireland Ambulance Service (NIAS). Is there any way to quantify that impact?

Ms Casey: For every visit that staff make at the weekend, they have to provide stats to show what would have happened if they had not been there. We have a table, and, if there is something happening regarding medication, they provide symptom management. At the end of every month, we tally that up. We have to provide statistics to the funders to show what they have got for their money.

We find that it is helpful for not just the patient but the district nurses, who are the key workers in palliative care. The district nurses find it to be such a helpful service at the weekend. Before, they could have been stuck with one patient all day, whereas, now, with our nurses being out, they can do a joint visit. They know what is happening, and they are not doubling up in time. We also have a nurse prescriber who can change a syringe driver chart and have it there for the district nurse. Before, the district nurse had to go to out-of-hours, get that chart and bring it back, and, if a prescription was required, the family had to leave their one loved one to go and get it. The weekend service is making it easier for the patient and gives them more quality time, when we do not know how long they have left. If a family member spends three hours on a Saturday trying to sort a syringe driver, and they come home and their loved one passes away, they have missed out on three hours.

We are gathering data, including on what it would have cost if our nurses had not been on duty and there had been a hospital admission. We can also now plan admissions to the hospice for a Monday, whereas, before, if the nurses were not on, you would look at your referrals on a Monday, and, because you had not had an update over the weekend, it could have been Tuesday or Wednesday before a patient got admitted. By that stage, the patient may have been too ill to transfer and missed out on their wish to die in the hospice.

Mr Donnelly: I can absolutely see how that has multiple benefits across the system and how it complements the statutory services. In many cases, as you said, you can step in before the statutory services are needed. You avoid inappropriate admissions to hospital and adding pressure on the ambulance system, A&E and GPs. It would be interesting to see a quantification of the impact of that.

Another thing that we hear regularly is that the public have the wrong perception of palliative care generally. What does the Department need to do to educate the public on the benefits of palliative care?

Dr McIvor: As you said, there is a general lack of awareness. A strategy with an educational component could raise awareness. There are a lot of negative connotations: people think that palliative care is just for end of life or even just for cancer patients. All that needs to be addressed. The advance care planning policy and the recommended summary plan for emergency care and treatment (ReSPECT) are sitting ready to go. They just need to be rolled out. If they were backed up by an education programme, that would go a long way to increasing awareness in general. It is not just a palliative care issue; the advance care planning policy, ReSPECT and general education are for everybody.

Mr Henderson: We deliver the Compassionate Communities Northern Ireland model, which is linked to the public health approach to palliative care. That is more community-focused: it looks at death, dying and bereavement across the community and not just for those who have a terminal illness. It covers advance care planning and things like that. A number of years ago, we looked at having a resource — an education officer — to look at engaging with nursing homes, community groups, local schools and local businesses, but it is just not affordable at this point. We do a lot of education and awareness raising. We link in with the All-Ireland Institute of Hospice and Palliative Care on Palliative Care Week and with Hospice UK on Hospice Care Week. We try to use those as opportunities to increase awareness among the general public. When our fundraising team goes out into the community, it gives little presentations or talks. A nurse or someone else from the medical team goes along with the fundraising team to provide a bit of insight into what we do in the organisation.

It is very limited and ad hoc, and something a bit more structured would definitely help, whether that is in each organisation or across the board.

Mr Donnelly: You talked previously about the bereavement counselling service that you offer for children and for adults. Can you give us a bit more detail on that?

Mr Henderson: Our Healing Hearts children's bereavement service is for children up to the age of 18, irrespective of the cause of death. It potentially includes children who have been familiar to us through our services, but it could include children who have been impacted on as a result of a road traffic collision or suicide or the sudden death of a significant adult in their life. That currently is 100% funded through our voluntary income and charitable donations. We also have a small amount of funding through the cancer charities relief fund to enable us to have an additional counsellor, because the demand for that service is significant. The adult counselling service is provided on a referral basis, and that is time-bound up to July or September, is it?

Dr McIvor: September.

Mr Henderson: September. We had a waiting list, and we had to close it because the demand for that service has been absolutely phenomenal. That is time-bound. Prior to getting the funding for that, we have a number of volunteer counsellors who have provided the service before. We are hopeful that, when this money runs out, we might still have access to those volunteer counsellors. It is the uncertainty around that that makes it a little more difficult to plan ahead.

Mr Donnelly: Those are amazing services that are being delivered.

Mr Henderson: Thank you.

Mrs Dodds: Thank you again. Like everyone, we are in awe at times of the services that you provide to people at their most vulnerable in their life. Maybe you can help me to understand your funding allocation. Is there a general formula for funding allocations to hospices for those core services, and how is that worked out? Is it the same for all hospice services?

Mr Henderson: I do not think that there is an actual formula. We get a block grant, if you like, of a certain amount of money.

Mrs Dodds: How is it calculated that Foyle gets this, the Northern Ireland Hospice gets that and the Southern Area Hospice gets something else? I do not think that, in any of the conversations that we have had, we have understood that. Maybe I am wrong, but I certainly have not understood it.

Mr Henderson: Whenever we are asked for some information, we are usually —. I think that there is a calculation that is loosely tied into the number of beds and the bed occupancy and looking at the statistics around that. We have asked the commissioners a number of times for a breakdown of how that money is carved out for our day hospice, for our community work and for our inpatient unit. We have never really got to grips with how much we are getting for each, so it is very difficult for me to say to you exactly what we get and what it is for. All we know is that it is a pot of money and that it is to deliver those services.

Mrs Dodds: That is quite remarkable, and maybe that is a question for the Committee to take up. I have not heard it articulated in that way before, and that is why these evidence sessions are absolutely invaluable. We want to make sure that everybody is getting what is appropriate to the region that they serve and what serves the needs of communities in that region. If we do not understand how it is allocated and on what basis it is allocated, that is an entirely different set of circumstances that we find ourselves in. That is perhaps something that would be very good to know. Everybody on the Committee knows that I ask the same question every time, because I am really quite keen that we see hospice services and palliative care as a core part of our health service. How would that change things for you?

Mr Henderson: In terms of what, sorry?

Mrs Dodds: We do not leave giving birth to charity, but we leave palliative care partly to charity. How would it seem if there were a legal requirement from the Department to commission palliative care to the required need? How would that change things for you?

Mr Henderson: It is very hard to know how that would look, but we would never want to lose that high-quality, individualised and holistic care. I mean no disrespect to anyone who works in the sector in saying this, but we are very clear, as I think colleagues in the other hospices would be, that it is not always about number crunching for us. We need to make sure that patients get the right care, in the right place, at the right time. That is one of the risks that we are very keen to see mitigated. I would expect there to be some further level of control if there were more significant funding for hospices. We are regulated by the Regulation and Quality Improvement Authority (RQIA) as well. I hope that there will be little, if any, change to that situation, because, as it stands, we are regulated strictly through that channel. One thing that we are very clear on is that we want to make sure that the service remains holistic and individualised and that it gives patients some choice about where they die.

Mrs Dodds: That is very important.

I apologise that I did not get up to see the hospice, but I think that the weekend service is great. You have to be a patient or have been referred to the hospice in order to access that service, is that correct?

Ms Casey: Yes. Even if the patients are not known to the team and a district nurse rings up looking for advice on that patient, the nurse will give advice to that district nurse. The district nurse can then go to the out-of-hours GP service and say, "I have spoken to the hospice team, and this is what they suggest", so it is kind of —.

Mrs Dodds: You have anticipated my next question. It sounds like a service that could be expanded and would be beneficial for people. I think that we would all like to see fewer patients receiving palliative care in accident and emergency situations. That would be beneficial for everyone involved. It sounds like a model that, if you had some contact with GPs etc, could be expanded and worked on in order to make it broader and wider. Is that true?

Ms Casey: Yes. At the minute, we have only one nurse to cover the weekend. In our northern sector, they cover Derry, Limavady, Strabane and Claudy. That is a big area. If one person were to go to Bellarena, and then for there to be someone in Clady in Strabane looking for —

Mrs Dodds: Yes. It is at the other end, really.

Ms Casey: — that nurse is stuck in a quandary. If there were two nurses, they could be at different bases, so it would not be a case of, "Who's nearest?" or "Who's most in need?". They could link in. The weekend service gives the district nurses a bit of back-up as well. We can say to them, "If you go to this patient today and sort them out, this is the advice, and then I will follow up tomorrow". It would make a lot of difference for patients if we had more members on the ground. On a Friday, we make a list of the patients that we think will need support at the weekend. There could be 10 on that list, but it may then be that three people that you did not think anything would happen to suddenly deteriorate, and that changes the whole mindset. If there was another person on the ground, it would make a difference.

Mrs Dodds: Could you join that up with, for example, the outpatient service?

Ms Casey: The outpatient service is only during the week.

Mrs Dodds: But, if more funding and more GPs were involved, would there be potential for you to provide that outpatient service at the hospice? We would all like to see fewer patients being traumatised by ED. We have to find some recommendations around that to try to help us. The outpatient service, the weekend service and that kind of thing is where it will be at, is it not, really?

Ms Casey: And even our 24/7 helpline — our doctor is in the inpatient unit at the weekend. They are getting calls from different people as well, like other GPs who may have known a patient, and even, sometimes, the hospital, if it has a query about symptom management. That line is in the inpatient unit. The staff in the inpatient unit are trying to look after the nine patients and give them their time, as well as take advice calls. Patients or their relatives are traumatised when they ring. They just want someone to help them. They could be told, "Look, wait 10 minutes and I'll get back to you". That 10 minutes can seem like two hours. There are knock-on effects. With the advice line, the doctors can maybe take a call and give advice. The patients are very appreciative of even a call back and having someone to listen. If they were to ring an out-of-hours service, it could be six hours before someone gets back to them, whereas we get back to them within half an hour, at the most.

Mrs Dodds: That really is invaluable. There are some really practical things that the Committee can think about from your presentation today. Thank you very much. I really appreciate that.

Mrs Angela McIntyre (Foyle Hospice): May I just say something?

Mrs Dodds: Of course.

Mrs McIntyre: The staff are absolutely wonderful; every one of them. Perhaps some not as much as others. [Laughter.]

They are all wonderful.

Mrs Dillon: Thank you all for your presentation. A lot of what I was going to ask about has been covered. Diane is right: it is vital that palliative care patients do not end up in A&E. You know better than anybody else that, when we get to the end of life, every minute, never mind every hour, counts. It is so valuable. It is so important that families and individuals are not traumatised in the middle of that.

You talked about what you could not do if you did not have the money. What I want to get an understanding of is — other members have taken us a wee bit of the way — if your inpatient beds were 100% commissioned and funded, what else could you do? You talked about therapeutic services and stuff like that, and that is vital. If we were able to get more of that —. You have actually talked about some of the stuff that you could do more of. It is just about getting a sense of what you could do if you had that help. When St Francis Hospice was in front of us, it said that, because it is 100% funded, it can do so much additional stuff. It still fundraises. It did not stop fundraising or providing other services — but it can do so much more of that stuff because it still fundraises. It does not have to worry about the running costs of the hospice, because those are covered, which means that it can provide additional services. Is there more that you could do if you were getting more funding from the Department?

Dr McIvor: We have mentioned some of those things that we could do if we were core funded. The weekend service that we have just talked about is time-limited. That is grant-funded money. Our outpatient service is time-limited. That runs from one year to the next. Our counselling service also runs from one year to the next. As we have said, the demand on the counselling service is such that we have had to close it to new referrals. That will come to an end in two months' or three months' time. Where is all of that demand going to go?

If our services were funded, the money coming in from fundraising could be put into those other services to make them more sustainable and develop and increase them. The effect, as Diane said, would be to keep people in their own homes, where they want to be, and care for them there. What is going to happen in a couple of years' time if that funding for the weekend service runs out? We will be back to square one. That has been the nature of palliative care services since their inception. There has been great innovation. Hospices are very agile; they can change things very quickly and come up with great ideas, but you find that a service is set up for a year or two and then the funding disappears. That is very disheartening for everyone.

It is about developing the services that we have and sustaining them. By doing that, we can also attract staff. We also have the issue of recruitment and retention of staff in the west. If we had sustainable funding like that, we could recruit. We have great staff already, but it is about keeping them. It is all part of it. If we made palliative care a core service — if it were funded for everyone to have a right to palliative care, as such, instead of people having to —. What is happening is that, in many aspects, people are paying for their own care when they receive palliative care. That does not happen in any other part of the service, does it? You are not paying for your own GP or cardiac services or whatever, so it comes down to fairness and equity.

Mr Henderson: To add to that, the strategic planning and performance group (SPPG) undertook a review of the day hospice model or day therapy services. There is an expectation, and we understand that expectation; we understand why it is that there will be more of a focus on clinical services. However, the important thing about our day hospice service is that we provide some complementary therapies as well, but, for those patients coming through, it might be the only time that they get an opportunity to meet people who are in the same situation as them. Whilst the clinical side of it is important, there is a social aspect to it as well, and we cannot lose that in its entirety, because it is important for those people to meet people like themselves who are going through the same process, the same emotions, and for them to form their own little support network, because no one knows how they feel as much as they do themselves. That is the kind of thing — health and well-being — that we could develop more.

Dr McIvor: A general, holistic approach.

Mr Henderson: Yes.

Mrs Dillon: That is perfect. Thank you, all. Other members have already said that it is much appreciated by ourselves and the wider community. Palliative services would not have been there for so many families if it were not for the charities and the hospices that are out there doing fundraising. It is very much appreciated. Thank you.

Mr Chambers: I apologise that I was not able to get to the visit to your hospice, but I heard great reports from it. The reputation of your hospice is that it is admired well beyond the Foyle area. I appreciate that and thank you for it.

You talked about the £1·8 million shortfall this year. Is that before the charity donations are taken into account, or is that a projected shortfall, even with charitable donations?

Mr Henderson: To clarify, that is what we have to raise through our fundraising efforts. Even with trying to raise that amount of money, we would still potentially be looking at a deficit of £600,000 or £700,000. That is what we aim to raise in the current financial year to balance the books.

Mr Chambers: Are you under an obligation to balance your books each year, or do you have the facility to carry forward a shortfall? I am not advocating that you should —

Mr Henderson: No, I understand.

Mr Chambers: — but do you have to balance the books?

Mr Henderson: Angela is better placed than I am to speak about that, but we take that decision through our finance and audit committee and, subsequently, to our board of trustees. At that stage, it is up to us, as a senior management team — Paul, Annmarie and me, along with two other colleagues, Sheila and Terri. We make sure that we have done all our homework beforehand to see where we can cut costs and identify ways to raise more funds through those short-term grants and things like that. We then present that to the finance and audit committee before it goes to the full board to look at. At the end of the day, it is up to the board whether to accept a deficit budget.

Mr Chambers: You talked about there being variables because you do not know how much you are going to bring in in charitable donations. Would you ever, as the financial year progressed, face almost a doomsday situation in which you have to suddenly stop a service in the interests of balancing the books by the end of the financial year?

Mr Henderson: Thankfully, we have not faced that to date. We have quite a robust financial management programme in the organisation. Our finance and audit committee meets every third quarter and has a quarterly report, which means that we are able to plan for the next three to six months. We look at our income and ask, "Are we on target? Are we raising what we said we were going to raise with our fundraising? Is there a shortfall, and, if so, is that likely to continue over the year?" if so, we would then have to look at our services. As a loose example, we have an integrative care clinic — Paul mentioned it earlier.

Dr McIvor: It is really our outpatient clinic.

Mr Henderson: That is the outpatient clinic. That has been running for the past 10 years. Whilst that money has not been taken away from us in the current financial year, the money has not been allocated for the purpose of running an integrative care clinic, so we have had to look at winding that down and at how that money can be utilised to support our community services in a different way. In the past couple of months — even the past couple of weeks — we have been trying to put mechanisms in place to ensure that the patients will not be left high and dry and we will be able to refer them to our other services or signpost them to appropriate services other than ours.

Mr Chambers: You talked about it being much better to have a three-year or even a five-year budget, which would allow you to create new services and recruit staff with a degree of confidence and assurance. I am sure that it is hard to recruit new staff on a one-year contract when you cannot give them any guarantee beyond that. Have you ever come up with a proposed new service or seen one somewhere else that you thought you could use and said, "Yes, that is a great idea", but then had to put it into cold storage simply because the one-year budget held you back?

Mr Henderson: Yes. The example that comes to mind has a recurrent cost, but it involves a capital cost initially. I mentioned earlier that we are not able to provide the same level of respite care in our inpatient unit as we did pre pandemic. We would like to provide that again, but doing so would require us to build between two and four additional bed spaces. We would not necessarily commission them all at the same time, but economies of scale would suggest that it is cheaper to build four rooms than it is to build two, and there would then be the recurrent cost of staffing to support those bed spaces. That has been in our strategic plan, but we have had to carry it forward for the second time because we do not feel confident about raising the additional money. The capital would be OK because there would bee a huge fundraising campaign — there is a capacity to donate to something tangible that you can see — but we would struggle with the day-to-day running costs. We are concerned that that might be a bridge to far for us at the moment.

Mr Chambers: That must be frustrating. Thank you very much for all you do.

Miss McAllister: Thank you very much for your presentation. I am sorry that I was late; I was at a Policing Board committee meeting that ran on. I do not have a specific question, so I just thank you for your presentation. It is particularly helpful for MLAs such as myself who are from more urban settings to get a bit of reflection on the difficulties for palliative care organisations in rural communities, so this has been helpful for me in that context. Thank you for that.

The Chairperson (Mr McGuigan): Thanks, Nuala.

Folks, that has been very useful. We really appreciate your coming before us, giving us your expertise and evidence and participating in our inquiry. Keep up the good work, and I hope that our inquiry report will do you all justice.

Mr Henderson: Thank you very much.