Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome to the Committee Dr Ursula Mason, chair, and Dr Emma Murtagh, vice-chair of policy. You are very welcome. Apologies for shifting the time. You will understand that we were meeting the Minister, and GP services was a big focus of that conversation. I will hand over to you to make any opening comments that you may have in relation to our inquiry into palliative care, and we will take questions from members thereafter.

Dr Ursula Mason (Royal College of General Practitioners NI): Thank you very much, Chair. Good afternoon, and thank you for the opportunity to present oral evidence. I am a GP from Carryduff, County Down, and chair of the Royal College of GPs in Northern Ireland (RCGPNI). I will let my colleague Emma introduce herself.

Dr Emma Murtagh (Royal College of General Practitioners NI): I am a GP in east Belfast, and vice-chair for policy at RCGPNI.

Dr Mason: Time, space, capacity and capability — those are all the things that you would want your GP to have in ample supply when you or a loved one need palliative or end-of-life care. GPs are an integral part of the delivery of palliative care for patients, embedded in communities with intimate knowledge of patients, their families and their life journeys. Often, we are with them for the diagnosis that led to palliation, supporting them through treatments to the point where curative care is no longer possible, and then helping them to live better through symptom control towards the end of their lives.

It is important to state that generalist palliative care is a core role for GPs, and there is good reason behind the continued use of the adage, "from cradle to grave". You will have heard from many of my colleagues from right across the health and social care system who have presented on the role of generalist and specialist palliative care provision, and I am not going to repeat much of what they said. Nor will I go into great detail about what palliative care is or what we deliver for patients, because you will know that already.

I want to give you the opportunity to ask us questions about our experiences and the challenges that we have, many of which we set out in our briefing paper. I want you to ask us why our continuity of care and knowledge of a patient is so important but also about our worries and the impact of the crisis on general practice and what that is doing to our workforce, workload and, ultimately, our ability to deliver a quality and safe service for patients. I want you to ask us about the challenges around prescribing palliative and end-of-life medication, and the impact of the fragmentation of IT systems as well as the geographical differences in care delivery.

Before I finish, however, and as Emma and I get ready to answer your questions, I would like to ask all of you two. Do not worry, I am not expecting you to answer them. I know how this works — we answer the questions, and you ask them — but I have just two questions for you today.

I would like you to think about a time when you were present towards the end of a loved one's life and to reflect on the care that they received. Was it a long time ago or more recently? Were there good experiences or not so good? What made a real difference in their journey or, indeed, in yours in how you considered the passing of that loved one? I also want to ask you about whether you had discussions with those you love about what the future might hold for you should something happen and what your wishes and considerations might be about not just the care that you get but how you live your final weeks and months.

Not surprisingly, I am asking you about advanced care planning, and I hope that you might want to ask us about that, too. For now, and for the future, the policy that was launched in 2022 is yet to be enacted. We have lost almost three years of opportunity to make a difference in how we consider and deliver care towards the end of all our lives. We need to get on and deliver that, ensuring that conversations and the resulting actions around our wishes are normal practice in our day-to-day lives.

Thank you for your time. We are happy to take questions.

The Chairperson (Mr McGuigan): Thank you. With regard to your first question, my mother passed away in 2004. The care that she received from her GP, the nurses and the community nurses was excellent, which eased the very sad experience of us watching her pass away. I have had no discussions about that yet, but maybe I will this evening over dinner.

I really appreciate your coming before us. This is a specific inquiry that we are having but we have focused a lot in recent weeks on GP funding etc. Therefore, it might be useful at the outset for both of you to give us a sense of issues such as workforce shortages, burnout and contract hand backs in general practice, and how those are affecting the delivery of palliative and end-of-life care. I think that I am correct in saying that, last week, Dr Frances O'Hagan said that 95% of palliative care was carried out by GPs.

Dr Mason: Yes, you are correct in saying that. It is a core role of general practice. We very much value the role that we have in the lives of our patients towards the end of their lives. One of our challenges is that we have to be able to do that as well as everything else. You will be well versed in the challenges that we have about access to care delivery across the population, and we have to carve out time in our day-to-day work to be able to provide a timely response to palliative requests and concerns from patients.

We think about our full day, and I talked about needing to be able to provide urgent and unscheduled care to our patients. We also need to be able to provide preventative and proactive care, chronic disease management, and the aspects of palliative care. It is about how you fit all those into your day, and how you prioritise them. There are some things that we absolutely have to prioritise, and palliative care is one of them. If I have a list of 20 or 30 patients to see, and there is a request for a palliative consultation, a query or whatever it might be, GPs just down tools and deal with that because they recognise the importance of their role in the delivery of good-quality palliative care.

That has a knock-on effect, however, and the challenges that we have around workforce, funding, the delivery of core funding into general practice and the resulting instability will have an impact, because there are only so many hours in a day; there are only so many GPs; and there are only so many actions that we can take safely in any one day.

The landscape and position that we find ourselves in mean that we are constrained in our ability to deliver for all our patients. However, I can say that, if you are a patient with a palliative care need or if you are getting towards the end of life, your GP will prioritise that. It is about the knock-on effect that it has on the rest of your workload.

The other thing that is important to comment on is that we often try to be proactive, strangely enough, when it comes to palliative care, because we recognise that, as people get towards the end of their life, their needs change. We have got to be able to be there when we can, so some practices and some GPs will often give their telephone number to a family when they are not working or when they are not on call or are not there. That is relatively commonplace. Those things matter to families.

The other thing to remember is that we do not only care for our patients. We are often the GP for the husband or the wife, the children or the grandchildren. We follow their journey and our journey — that journey — goes on beyond the passing of a loved one. Knowing what has happened in those environments, in those situations, is key to being able to deliver quality care for our patients beyond the passing of that loved one.

Do you want to add anything else?

Dr Murtagh: Being a GP and delivering palliative care to a patient is, without doubt, the biggest privilege that I have ever had and ever will have as a GP. It is challenging because there are really emotive things: you are sometimes dealing with young people and because you have the context of what it means to that family. When I think of the last patient with whom I dealt with palliative care, I know the family inside out; I look after many of the family members. I had seen the disease from its start to its end. I had seen similar disease in other family members, and I knew all the contexts. So, it makes it a privilege, but it also makes it quite challenging, because you are carrying all of that on your shoulders, which need to be broad.

Just as Ursula said, we will down tools. We will go. We will sit. It all takes time. Certainly, the prescribing and the coordination, which is a lot of what we do, takes time, but sitting down on the bed with the patient and explaining to them what their last weeks and days will be like is so important — and that cannot be done in five minutes or 10 minutes. That takes an hour; it may take an hour and a half, and by the time you get back to surgery and sort out the prescriptions and maybe speak to a district nurse, a community team, you are suddenly two hours behind, and everyone else is still waiting. We need time to do it right and you get once chance at that. You get once chance at good palliative care, and it has to be done correctly. However, it has a knock-on effect on other things, and that is what I am concerned about.

The Chairperson (Mr McGuigan): That is a very good point: once chance.

Mr Donnelly: I declare an interest as a nurse who has previously delivered palliative care in a hospital setting. I have certainly seen the huge benefits to patients who have been suffering incredibly and have been made comfortable in those final days and final hours of their lives. As you mentioned, it is a privilege to be there and to be part of that. It does have a massive impact on the family and those who are left behind with memories of that time. Knowing that a loved one is comfortable when they pass is a huge comfort to those families and palliative care is absolutely vital.

I want to pick up on a couple of things in your report. You mentioned geographic inequalities. It is something that you asked us to ask about. You mentioned two patients with the same GP service, but in different trusts, having different experiences. Can you broaden that out a wee bit for us?

Dr Mason: That can happen relatively frequently. If you think about the provision of palliative services across Northern Ireland, even something as simple as the fact that — well, we could start with the basics: one GP practice could be really unstable and not have very much GP provision, or it might have handed back its contract and is being run by locums, but they are being asked to deliver the same type of service as a practice that is maybe well staffed with doctors in an area where they have good provision. Then, we think about district nursing services: not everywhere across Northern Ireland has a 24/7 district nursing service, so the ability to respond in a timely manner to someone who is, perhaps, needing end-of-life medication in an out-of-hours setting may be different. Also, the ability for GPs to refer for specialist palliative care provision is different across the trusts.

We often find that while, on paper, it feels like all those things should be there, or, in some shape or form, they are there, but it is not universal. We would love to see the ability for that to be universal right across the board, not least for someone like me. In my practice, two thirds of my patients live within the Belfast Trust boundary, and one third live in the South Eastern Trust area. There are many GPs like me, who have patients who cross two boundaries. There are nuanced differences between the mechanisms, referrals, the people whom we talk to and the services that they get, and I need to know what they are. If they were all the same, it would be so much easier.

Ultimately, it does not matter whether you are in Castlederg or Castlewellan; technically, we should all be striving to deliver the same service. That does not matter whether it is a district nursing service, a GP service or a specialist palliative care service. We should be able to do the same for all our patients.

Dr Murtagh: A lot of it is because a lot of the services are delivered by charities. There can be significant differences when they are not trust-led. There is a danger that there are services that I, as a GP, do not know about, which my patients could have availed themselves of, but, because I did not know about those, I did not refer them.

A lot of my patients are also based in the South Eastern Trust area, and a lot of them are in the Belfast Trust area. Even the simple ways of how you refer can be different. There has been a lot of work done in Belfast recently, and there is now one pathway and one mechanism for referral, which is excellent. It is so joined up, and, hopefully, we can continue in that same vein.

Mr Donnelly: Secondly, one thing that we have heard time and again relates to your second question about having those conversations with people and how important advance care planning is to know what a person's wishes are in their final days, how they want to be cared for and where they want to be cared for.
One issue that we have heard about time and again is that do not attempt cardiopulmonary resuscitation (DNACPR) decisions seem to stop when people leave hospital. In fact, they continue in an ambulance, and then they stop when a patient gets home. How do we join that up? How do you see a solution to that?

Dr Mason: There is a really easy way to do that, and that is to enact this document: 'For Now and For the Future', which is on advance care planning. It is not just about DNACPR or asking about last wishes around clinical care; it is about the whole of life. It is about your financial situation, your social situation and a legal perspective. It encompasses everything, but clinical decisions is one big part of it. Part of that is about having conversations about what you would like to happen at a time when you are not able to make those decisions for yourself. You are thinking about the future, you are talking to family, you are writing it down and you are saying to people, "This is what I want and need when the time comes". You can have those conversations at any stage. We should all be having them.

Culturally, in Northern Ireland, we need to move to a position where that becomes the norm and not just when you get a diagnosis of something really nasty and the end is in sight. It is about what we talk about, what we think about, what is important and making those wishes known to those around us who love us and enact those for us when the time comes.

Part of that is the 'Recommended Summary Plan for Emergency Care and Treatment' (ReSPECT), which is a document that encompasses DNACPR. You are absolutely right to say that it stops at the point where you transition from one place to another. That can be from an ambulance to a trust, from one trust to another and from secondary care services back into primary care. It is a bit silly to think that, in this day and age, we have to keep doing that and have to keep having those conversations with families. Can you imagine being a family member with a loved one who has lost the capacity, and you have to have a conversation around best interests and what they might have wanted? If you have not had that conversation, you would feel the burden of that on you, and you would be thinking, "What would they want? What do I think they want? What do I want?".

Those are really difficult conversations, but imagine having to have those in the emergency department or, before that, in the ambulance. Then, you come out of hospital and somebody else has a conversation with you, and then the GP arrives, and they have a conversation with you as well. It must get very difficult for family members of loved ones or the individuals.

ReSPECT is a document that would travel with the patient. It is a single document that would sit right across the region. It would not matter where you were. It would outline your wishes around treatment and about CPR and that decision to say, "I do not want CPR to be enacted in the event that my heart stops". It is a much bigger thing than just CPR, but it would encompass a lot of what we need to do to make that seamless for patients, remembering that it is a live thing and that it can be changed and can be flexible. You do not have to say, "If I have made my decision that is it, I cannot change my mind". Things can change and it is important that that is communicated as well.

If we could roll that out, enact it and deliver it, it would make such a difference to many people. It would make a difference to individuals who are reaching end of life and to family members but also to you and me. At least if I have had that conversation, I know that my wishes will be respected insofar as they can be, depending on the circumstances.

Mr Donnelly: Yes, absolutely. I find it amazing that it has not been done already. I have seen circumstances where people are distressed by having to have that conversation again and again. You will be removing the burden of a family member having to make a decision on your behalf, not knowing what you want, which is an incredibly stressful thing to have to do.

Dr Mason: Absolutely.

Mrs Dillon: You have answered a lot of what I was going to ask you, Ursula. The answer to your question is yes, and I am not going to talk about it or I will become known as the Assembly crier. It makes a massive difference to a family when you know that the person is having the end-of-life experience that they want and that you want for them. It is not even about that point in time but the post-death trauma. I have also spoken to people who have not been so lucky. We are going to be speaking with people with lived experience — I am sure that we will hear a bit about that — of a situation where a loved one has not had that end-of-life experience and the family member has not shared the experience that they would like to have had with them. The post-death trauma that that causes is insurmountable in some cases and can last a lifetime.

What could help GPs in that regard? A lot of what we have heard about is around the funding model for hospices and things like that. What additional work could they do in the community if there was better funding for core services that hospices deliver? Not all of this needs to be delivered by GPs. What would be of immediate assistance? There is a postcode lottery around the services that are available in different areas, and a lot of that is because we do not have statutory core funding for hospice or the Hospital at Home service or for whatever we want that model to look like.

Is there something that you can point to that would help you to help your patients? If you were able to say to someone who is at the end of their life that rather than calling you, hoping that you are going to be able to leave your surgery to go to them, what is it that you would want to have in place? I am not saying that it will replace what you do, because there are things that cannot be done by anybody else, and we need you to be able to do those things. However, we probably need you not to be called out of your surgery to do the things that other services are there to do.

Dr Murtagh: I feel that GPs are really well placed to do palliative care, for all the reasons that we have discussed. That is a core part of our work, so I would say that there are other things that we do that other people could do, but palliative care is one of the things that I would want to keep. I do not know whether you agree with that, Ursula, but that most certainly is what I feel.

Dr Mason: Absolutely. We want to be able to provide seamless care for patients when they need it. We are in a position in the community, for the reasons that we talked about — our knowledge of the patient, their family and their situation — where we can probably deliver really well for patients. Our challenges, however, are in the other bits that we are not necessarily doing.

There is something, though. You talked about the core role of our colleagues in hospices and specialist palliative care provision. More and more people are going to die because more people are living longer with complex conditions and our population is growing. Having looked at the figures, we know that the need for palliative care will increase over the next decade, probably quite significantly. We also know, however, that not all those people will need specialist palliative care provision. Most of them will just need generalist palliative care provision. I know that one part of the Committee's remit is to look at the state of play across specialist palliative care. My argument is that it is really important to count and measure all palliative care provision. That means the stuff that happens in general settings for the people who are seen by only the GP and the district nurse, because that is all that they need. It will take everyone if we are to be able to deliver really good quality palliative care, but we need to join the dots up between those of us who are doing it at a generalist level and the specialist services.

The Chairperson (Mr McGuigan): Sorry to interrupt you. Linda's question was about what can be done to help, and your answer was about the fact that GPs are better placed than others in a lot of cases. How can we help GPs to allow them to do that better?

Dr Mason: We just talked about it when you asked the question on the challenges of where we find ourselves. The reality is that our general practice service is unstable, at crisis and underfunded. That is the simple thing that could be done. If we had a stable, secure, well-funded and well-resourced service with a workforce that was fit for purpose, we would be able to deliver more. We will always down tools and go and provide palliative care for patients, because it is a really important part of a GP's role. However, if there were more of us, the knock-on effect on the other patients would not be as severe. I would not have to apologise to someone for being two hours late and say, "I am really sorry. I had to go and see someone". Our patients really understand that. When I say to someone, "I am sorry. I was delayed because I was seeing a palliative care patient", there are no arguments, because people understand the importance of that. Communities really value good palliative care. However, we need to make sure that we have a stable service.

The worry is that the more unstable we become, the less able we are to deliver. We would then find ourselves in a difficult situation, because, again, it is about the core of what GPs do, from cradle to grave. If you start to undermine that, you really take away from what exactly we are in our communities and what we deliver. We need to stabilise.

There are bits that we could do to make joined-up working a bit easier when it comes to the referral processes, IT systems and all those things. I know that my colleagues in palliative care will say that we need to strengthen their workforce and have more of them. We will need more of everyone; it is not a "them" and "us" situation. It is about asking, "Can we make the provision across generalist and specialist services something that fits well together, communicates well and has smooth interfaces and transitions so that patients get what they need when they need it?". It is about making sure that people who need specialist care get it in a timely fashion and that, when that is done and they can move back into a generalist setting, those transitions are smoother and more joined up.

I think of the whole aspect of prescribing. At the moment, one of our roles involves us often being called on by specialist teams to prescribe in a generalist setting, because they do not or cannot, because of the way that the pathways and mechanisms work. We are often in a position where someone is in a specialist setting, and they might be moving from a hospice to the community or where they have been in the community, but we are the key person who has to stand over and write those prescriptions. There is something integral about what we have to do. We need to make sure that the links between us, our district nursing colleagues and specialist providers are as robust as possible. Fixing our core would fix an awful lot.

Dr Murtagh: I will say some words about prescribing. We have talked about electronic prescribing for so long, but e-prescribing would make a major difference in palliation. So many times, I have written a prescription in a patient's house for injectable medications for a syringe driver, and those patients are in their last days of life. The patient's family have to take the prescription, and sometimes they have to drive around multiple pharmacies. That is OK where I am, in east Belfast, as there are many pharmacies within a stone's throw of where I work. However, I originally come from a rural area, and people there might drive for 20 or 30 miles for someone to find stock. They waste that time, which could have been spent with their loved one. Electronic prescribing would make a major difference in that and in many other things.

Mrs Dillon: I have heard that point before, but I am not sure that we have heard about electronic prescribing in any other evidence sessions. I think that you are 100% right. It is one of the biggest challenges, because prescriptions can change daily as you move through the journey. That is exactly what happens. Somebody comes in and says, "I think that the dosage needs to be increased". They write it up, and you then have to contact the doctor. The doctor does the prescription, and then somebody has to go to lift the prescription and find a chemist to take it to. You might be told to come back and lift it later.

That is grand if you have a family the size of ours and are lucky enough to have all the support that we had. If, however, you are on your own or rely on one or two people, if anybody, it is almost impossible.

Dr Mason: You could be doing that and then almost miss someone's passing because of the way things work. It is devastating to think about missing precious hours with someone at that time of their life.

Mrs Dillon: Yes, that issue has been raised. Thank you.

Mrs Dodds: Thank you for everything that you do. I realise how challenging, but necessary, the service is.

When we started the inquiry — it seems like a long time ago; maybe it is not, but in my head it is — we were informed by Mr Cassidy that the Department did not really know what palliative care services were out there but that they were going to do a piece of work to try to bring together that knowledge. Has the royal college been part of that work?

Dr Mason: No, we have not been involved in that at all. We are not aware of that, other than having heard the Committee talk about it in discussions with other people who have given evidence. I think that it would be —.

Mrs Dodds: I will stop you there, because that is almost fantastical, in a week in which Health has produced some fantastical issues. You deliver the vast majority of generalist palliative care to the vast majority of patients, and you have not been involved in that work. Is that accurate?

Dr Mason: That is right. We would happily get involved and would be keen to support any work that looked at what GPs provide. Essentially, you would just need to count the heads in general practice, because every single GP is involved in this as part of their day-to-day work.

Mrs Dodds: I hoped that that piece of work would not just involve, "This is a list and a number of all the GPs, and obviously they do palliative care", but "This is what they do; this is what they are saying; this is what we could improve; this is what we need to know about coordination with the community and voluntary sector and with charities". Has none of that happened?

Dr Mason: Not to my knowledge, and we have certainly not been approached to provide any input.

Mrs Dodds: One thing that the Minister said in the Committee's previous evidence session that disturbed me — it was in answer to a question from Nuala — is that increasing numbers of cancers are now being detected in A&E and that outcomes are poorer for those cancers because they are detected in A&E, at which stage they may more advanced. Am I right to say that?

Dr Mason: There is probably a bit of context to add to that. There will always be cancers that are easy to detect and that are detectable at an earlier stage because of the nature of the symptoms, and there are quite a number of cancers that, because of the non-specific nature of the symptoms that people present with, are often diagnosed at a later stage. When someone presents at a late stage or has advanced disease, they often present in extremis and may find themselves in an emergency situation. We know that the vast majority of patients with a cancer diagnosis do not go through an emergency department but through a GP referral. That may be a red-flag referral or a non-urgent referral, but it is a referral nonetheless. There is a percentage who present to emergency departments. There is a document from Queen's University that looked at rates of cancer diagnoses that shows that about 23% of people presented to an emergency department in, I think, 2018 to 2021. When you look at the trends, however, you see that the number of patients presenting at an A&E slightly decreases, with more patients presenting through red-flag referrals or non-urgent referrals.

There is a subset of cancers that are more likely to present at a late stage: things such as ovarian cancer and brain tumours, which often present in things such as seizures, which are very acute in their presentation. We also know that there are illnesses like pancreatic cancer or cancer of the bile duct, which, again, have very non-specific symptoms, so it is hard to say, "Yes, I think that you might have cancer and I am going to refer you". In comparison, if a woman develops a breast lump, it is there, it is very obvious; they will often see their GP and they will be sent red-flag. We are still seeing quite a number of patients present through an emergency route, but we will always see some patients like that because of the nature of how some cancers present.

Where we can make inroads in getting people diagnosed earlier — because we know that, again, earlier-stage cancer diagnosis improves outcomes and survival rates — is access to GP services. We have talked to this Committee before about how we are really worried about the patients out there when they phone, time and time again, and they are asked by the receptionist, "Is it urgent?" To them, it is a niggling worry, so they cannot really say that it is urgent, so they do not get seen. Then a week or a month passes — or a couple of months pass — before they finally come to us. Those are the people whom we are really worried about missing. Those are the people who, perhaps, are the ones squeezed to the side when we are having to deal with palliative patients and who fall foul of our access issues at the moment.

There is also the aspect of screening. We need to encourage more people to be screened for cancers that we have a screening programme for. For example, we would like to see bowel cancer screening moved from 60 down to 50, to screen more of our population. We are encouraging people who ordinarily would not turn up for screening. We need to be able to get out there and reach out to hard-to-reach groups and say, "Come for screening, because it really can save your life". If we can increase the number of early-stage cancers diagnosed through screening programmes, we will have better health outcomes.

In answer to your questions, we will still see people come through emergency departments, but there are lots of things that we can do as a system to reduce that number. Hopefully, that has answered some of what you have asked us.

Mrs Dodds: I was surprised by that number of 23%. I worry that that is a very traumatic event for people. It is traumatic anyway, but it is a very traumatic event for people in the general sense. They may well have a very good outcome, but it is just traumatic.

There are two last questions that constantly bother me. Do you find that the vast majority of your patients are able to have that end-of-life time that they want at home with their family? Is that where it is? I have recently heard some disturbing stories of patients who have had to be rushed to A&E and who have perhaps died with their family not present or with only part of their family present, and it has been very difficult for those patients. Are we still seeing the majority of patients being able to be cared for at home?

Dr Mason: Certainly, my experience is that, as far as we possibly can, we try to support people in their homes or in their preferred place of death. Some people would prefer to die in a hospice setting. Where we can, it is about having those services to provide, in the community, in a timely fashion. It is important to note that, in doing so, particularly where a patient has lots of complex symptoms or when you see an acute deterioration that may be something that is reversible, there will be times when conversations will be had about how and where that is best managed, so it would be wrong for me to say that patients do not end up in A&E. Should we be striving to make sure that we bring whatever care we can to that patient? 100%. Is that about making the services that we have in the community more robust and more able to respond in a timely fashion? Absolutely, because some of that is because that patient has a symptom at that time, and that symptom or the needs of that person cannot be met in a community setting in a timely fashion. That often triggers the move to an A&E. We should be able to move from a position where that becomes the default to the default being that that community team is already there, it can step in at a moment's notice, and it has the capacity and the ability to deliver that degree of care to that patient at the time.

Mrs Dodds: I am taking from that that expanding the ability of the community team to respond is important. However, perhaps having the proper protocols in place in A&E to deal with patients who are specifically in that situation is also important. I am not sure that it always is.

Dr Murtagh: I know that there has been some palliative care outreach procedures within EDs, but, again, it is piecemeal; it is not across the board. Another thing in answer to your question, Diane, is that there will always be complex symptoms that we just cannot manage. Sometimes we have to put our hands up and say, "Look, while A&E is not an ideal place for anyone in your situation, it is the best place for you because this cannot be managed". Social care is also a big issue. Patients can go downhill really quickly, and sometimes there is a real crisis of social care and there just is not the family — the 10 children — there to look after the person. They sometimes end up in A&E because there are no respite beds in a nursing home, which may not even be appropriate, and there are no hospice beds. That can sometimes be a real crisis, and it ends up that A&E is the only place where they can get the care that they need.

We also talked about advanced care planning and the ReSPECT form. We hope that, if that is rolled out across the region, those things may happen less and less. They will always happen to a degree, but if we all know what everyone's wishes are, then, hopefully, they should happen less.

Mrs Dodds: Thank you very much. I think it is important. Chair, perhaps, we might want to write to the Department and ask exactly who is part of that exercise and why such an important element of palliative care has not really been included in it.

The Chairperson (Mr McGuigan): That is a fair point.

Dr Mason and Dr Murtagh, we really appreciate you taking the time to come and share your evidence with us. We have learnt new stuff today for our inquiry, so we appreciate that. Thank you very much, and apologies again for the shift in time.

Dr Murtagh: Thank you for having us.