Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome the departmental officials. We have Gearóid Cassidy, director of primary care; Roger Kennedy, programme director in the community care directorate of the strategic planning and performance group (SPPG); and Ryan Wilson, director of secondary care for children's palliative care. Gentlemen, you are all very welcome. I hand over to you for some brief opening remarks.

Mr Gearóid Cassidy (Department of Health): I will make some brief remarks, Chair, and then we can get straight into questions.

Good afternoon. Thank you for the opportunity to return to the Committee today as part of the inquiry into access to palliative care services. I am the director of primary care in the Department of Health. I have policy responsibility for adult palliative care and hospice services. I am joined by Roger Kennedy, who is a programme director in the community care directorate of SPPG, and Ryan Wilson, who is director of secondary care and has policy responsibility for children's palliative care and hospice services.

We were here previously on 16 January, at the outset of your inquiry. Since then, you have received written evidence from a wide range of organisations and individuals. Members have also heard oral evidence from a number of stakeholders and, importantly, from people with lived experience of palliative care. You have also visited hospices to see and hear about the valuable role that they play in supporting and caring for people with palliative and end-of-life care needs. The evidence that the Committee has received has clearly demonstrated the commitment, knowledge, expertise and passion of those who make up the palliative care community and of those who have lived experience of palliative care services. The evidence has also highlighted vividly the difference that palliative care can make for people with life-limiting conditions and their loved ones. We know that our population is ageing, with more people living with long-term and life-limiting conditions, often with more complex symptoms as their conditions progress over time. As our population demographics change, the need for good palliative care will continue to increase, and what those needs look like will continue to evolve. Helping people with a life-limiting illness to live as well and as fully as they can is at the heart of palliative care. As the Committee has heard, good palliative care is about not only clinical care but the whole person, understanding and responding to the physical, emotional, social and spiritual needs of a patient. It is about providing care and support that is tailored around the person, with the emphasis on their quality of life.

Contrary to often-held misconceptions, palliative care is not just about cancer, nor is it just for end of life; rather, a palliative care approach can be beneficial for years after diagnosis. In that context, palliative care can be part of, and complementary to, the business as usual of providing healthcare to patients depending on their individual needs. That is why it is important that palliative care is seen not as a service apart but as an integral part of our health and social care system. As an example of that, the Committee heard last week how work is being taken forward through the winter planning work, with a focus on end-of-life care and advance care planning within the big discussion. In addition, as part of its strategic agenda to reset our health and social care system, the Department is looking at the concept of a neighbourhood model, which will provide the opportunity to consider how palliative care is delivered in communities. The Committee has heard evidence from colleagues in the palliative care in partnership programme and will be very aware of the role that it has played over the past nearly 10 years in developing palliative and end-of-life care services regionally and locally. The Department wants to further improve and develop palliative care and ensure that more people have access to the support and services that they need. To that end, the Department welcomes the Committee's inquiry and its contribution to that. We also welcome the opportunity to respond to the issues that you wish to explore and take any questions that you may have.

The Chairperson (Mr McGuigan): Thank you very much for that. I have a few questions. We have taken a lot of evidence on this issue, and the issue of funding always comes up. Your paper says that the Department provides 50:50 funding for services, but that is not what we hear from those who provide hospice services in particular. Can you explain to us the basis of the 50:50 funding? We are hearing that it is based on an equation that is not equal, in that you base it on a hospital bed scenario, whereas palliative care with specialist services is much more expensive.

Mr Cassidy: I will respond initially, Chair, and maybe Roger can come in with some detail. You are correct: the current funding model is 50:50. The first point we would make is that that is 50% of the commissioned service, rather than the total cost that the hospice incurs in the delivery of care. Hospices obviously deliver services that we do not commission; they have a wider care offering in that space. The comparator for that is based on a general medical bed. That has been the case for several years. It has been reviewed twice over the past decade — in 2014 and 2019 — to make sure that the comparator remains appropriate. In both instances, it was felt that it remained an appropriate comparator.

The Chairperson (Mr McGuigan): Sorry, just before you move on, will you explain why it was felt that it was an appropriate comparator? As I said, all of the evidence that we have taken seems to suggest that it is not a comparative comparator, and that you are assessing a general hospital bed to something that is very specialist. I would like to know, from your point of view, why you think that it is an appropriate comparator.

Mr Cassidy: Roger would be best placed to answer that.

Mr Roger Kennedy (Department of Health): I will take that, Chair. It is a long-standing planning assumption that goes back to 2004 about the cost of a general medical bed being used as a planning comparator, if you like. What Gearóid said is true: meeting 50% of the contracted cost is not reflective of the hospices' actual costs. It is an interesting topic in terms of what "good" looks like as a fair and robust comparator that gives us value for money and also gives a fair payment for that inpatient bed. There is no straightforward answer to what "good" looks like there. I met Hospice Alliance, all the hospices and Hospice UK last week, and, as part of our process for this year on the costings and any uplifts, I put it to them to provide us with a suitable cost, and they could not do that. That is the challenge.

The Chairperson (Mr McGuigan): Sorry for interrupting, but things just pop into my head. You are putting the question to the hospice, but I could put the question to you that there are scenarios, for example in Antrim Hospital, where there is fully commissioned palliative care. Surely, there could be an easy enough assessment of the accurate costs, if they are fully commissioned and fully resourced in Antrim, from your point of view.

Mr Kennedy: I think that to get a true, accurate and fair cost base, you would have to come up with a service specification for the inpatient provision, and that is something that we do not hold at the moment. That would be a driver to get a full, robust and independent cost model, which would be essentially taking us into a financial review again.

Mr Cassidy: Just to build on what Roger has said, when this was looked at previously, it was not just a single comparator that was used. It looked at the cost of a general medical bed, geriatric medicine, thoracic and cardiology, so a wider range of comparators was used. That work was undertaken with expert support. Marie Curie was involved in that review. It is not just the Department's view; we have engaged with stakeholders. You will have heard from evidence that some of the hospices think that we do not have the level of that right. There is something around whether our costing per bed has kept pace with the growth in costs over recent years, and Roger is leading on work to uplift that cost. It is still a comparison with the general medical bed, but it is uplifting the cost of that. We had undertaken three years ago to give a fuller and wider review of adult specialist provision, and as you will be aware, we have not been able to progress that as we originally intended. It is not off the stocks, but it is not currently in the programme at the moment.

Mr McGrath: OK. My last point on the funding issue is that a lot of hospices are running at deficits. For example, some of them told us that, because of funding, they will not be able to provide the services that they are currently providing. In some cases, we heard of a lot of inequality in service provision across the North. Some are providing services because they have funding for it, and some are not. Has the Department done any assessment of the cost to the Department should hospices reduce the services that they are doing? Somebody is going to have to meet the cost.

Mr Cassidy: I am sure that we will come to the scoping exercise that we talked about previously. I noted your comments last week, Chair, so I am looking forward to that part. Understanding properly what the palliative care landscape currently looks like is a missing piece of our puzzle. We said, when we were last here, that we really want to get a proper baseline on that, which will include what has been provided in hospices but also what has been provided in community teams. Obviously, the majority of palliative care is delivered in generalist settings rather than specialist settings. There is work on that. We have not looked specifically at, for example, if something were to stop here, what the impact would be. Getting a proper sense of what provisions look like and looking at where any commissioning gaps might exist will give us a better sense of what costs are associated with that. It will not ask the specific question that you have asked, but it will give us the information that we need on the back end of it.

The Chairperson (Mr McGuigan): OK. I am sure that other members will pick up on that and go into more detail. On the scoping issue, even in your paper —. Everybody who has come before —. Funding and the scoping exercise have been the butt of criticism from the sector and those who provide the service. The information that we have received about the scoping exercise talks about what the Department will do. It is about things in the future, but our understanding is that the scoping exercise is ongoing. We have heard criticisms about who is involved and who should be involved. I would like you to give us an up-to-date assessment of the scoping exercise.

Mr Cassidy: First, when I was here in January, I was perhaps overly optimistic about how quickly we could progress that work. When we spoke, I said that, with a fair wind, the exercise would be up and running in April and that it would take six to nine months to complete it. I wrote to all our stakeholders in April to set out the terms of what we were trying to achieve through the exercise and try to make some progress on it. Progress has been slower than we hoped. Part of the delay is down to the issues that you have touched on around what is in scope, what is out of scope and how we define that. We received correspondence from the Committee on the back of some of the evidence that you had received about whether we should look at a specialist-only review or whether it was appropriate to look at the issue more widely. We remain of the view that the wider scoping is appropriate, primarily because that is where most of the care happens, but also to get a proper sense of where there may be gaps in service.

We had a really constructive meeting with the palliative care in partnership board two or three weeks ago — recently — at which a project initiation document for the review was on the table. It outlined the review's key workstreams, what would be in and out of scope and how we wanted to progress the review over the coming months. At the meeting, there was a pretty robust discussion about why the review did not focus on specialists, whether the scope was correct, what we mean by "generalists" and how you define that. I will not say that there was unanimity about the scope, but there was consent that it was a good piece of work to get on with, and the board was content for us to progress it along the lines of what we had done. I will try to keep myself right on this: there are three work streams. One is on the baselining of current provision; the second is on a population needs assessment, which means looking first at the current landscape and, secondly, at the need that is not necessarily being met; and the third is on quality of care, in which the patient and service user experience will be really important.

The first workstream is scheduled to have its programme board meeting in August. With leave commitments, it was not possible to organise that any sooner. Questions still need to be ironed out on definitions and what we mean by "specialist" and "generalist", but there was at least consensus, albeit not unanimity, that it is appropriate to look at the full service and not just a specialist service. The next order of business, once we get the group convened with appropriate membership, will be to set out the detailed plan and the timescale for delivery of that. We are likely to go to an outside provider to do the second strand for us around the needs assessment. Roger, you can keep us right about the procurement. We have not yet got the provider for that. We initially thought that we would use the universities, but the Public Health Agency (PHA) may be the appropriate provider to take it forward. There is a piece of work to do to make sure that we take the right procurement approach, and then that work can progress. We have funding in place to allow it to progress. The third workstream is on quality of care. The discussion at the palliative care in partnership board outlined broad support for that piece of work. We were looking for willing volunteers to participate in that workstream, and there is more work to do on that.

That is the general landscape. The exercise has not progressed as quickly as we had planned, but it is fully in train. Some of what you have heard —. For example, the Royal College of GPs said that it had not been approached, but, through the palliative care in partnership board, all the stakeholders were approached, and everyone has had their say, not just on the scope and terms of reference but on the planning and the key objectives.

The Chairperson (Mr McGuigan): You are saying that the Royal College of GPs has been approached, and it is saying that it has not.

Mr Cassidy: It was after her appearance here. It had already been planned that that meeting would happen; it was not hastily arranged to cover a gap.

The Chairperson (Mr McGuigan): Some members may express deep disappointment that we have not progressed further. You are not even giving us a timeline for when a lot of this work is going to be completed.

Mr Kennedy: We have a draft programme initiation document. In that, there are draft timelines. We are looking at April/May 2026 for the completion of all three actions.

Mr Cassidy: I am wary of giving a false timeline or a timeline that might prove to be incorrect. That is the current planning assumption.

The Chairperson (Mr McGuigan): OK. I have lots of questions, but that would be unfair. Diane.

Mrs Dodds: Thank you, Chair. Thank you for the presentation. Where to start? I will start with the assessment of palliative care. Why did the Department not have any ideas about what palliative care was out there, or the extent of the palliative care that was out there, etc, given that the Department funds quite a bit of it? Why did you not know? Is that not negligence?

Mr Cassidy: We have full line of sight on the services that we commission. We have full line of sight of what the Department is responsible for, and that is performance-managed, and there are contractual agreements for those things. However, other arrangements are in place at local level between trusts and hospices or other providers, and, because we are not involved in those contracting arrangements, we do not necessarily have full sight of what is in scope there. One of the purposes of the review is to make sure that we have a 360-degree view of what is out there.

Mrs Dodds: That, in effect, means that, for the past whatever number of years, the Department has been content with a palliative care landscape that is full of inequalities — a landscape in which one trust will provide one thing, another trust might not provide it and another trust provides something different, etc. You are only now doing the scoping exercise to try to ascertain the full picture of palliative care. That is probably where we are.

Mr Cassidy: I would not characterise it in that way necessarily. Since the end of the last overarching strategy, there has been a lot of development in the palliative care space, overseen by, and with strategic direction from, the palliative care in partnership board. That has led to commissioning at local level by trusts or hospices and other providers. Hospices have been able to respond to emerging need more quickly, and perhaps have made services available. When I say "emerging need", I do not mean just in response to COVID; there have been other scenarios too. There is a natural evolution of things. Now is the right time to take proper stock of that, with the aim of making some proper, evidence-based decisions around how we see commissioning going forward, once we have a proper, firm evidence base for what provision is like and are able to assess if there are gaps and things that need to be addressed. A certain demand has been commissioned centrally, and there has been other local commissioning, if you want to call it that. Our ability to have full sight on that is important.

Mrs Dodds: Gearóid, you make a good attempt at responding to that question. We have sat through hours of advice. From the advice that we have been given from very senior practising clinicians in the palliative care space, we know that they do not believe that there is any kind of equality. They do not believe that there is enough information. They do not believe that every patient gets the care that they deserve. That is worrying.

One last word from me: you came to the Committee, gosh, 10 months ago — September or October last year — and said that this exercise in assessment of palliative care need was going to go ahead. Most members of the Committee probably thought that it was going to go ahead very quickly. You have now given us a process which is really just "how long is a piece of string?", and it will go on and on. I suggest — I do this with a heavy heart, and I am not trying in any shape or form to sensationalise it — that people out there do not have time for this, and they need you to act. This kind of processing our way through everything —. I have been in Government and I understand that process is good and it protects you: I understand that. However, what you have described just now to the Committee is a very long, extensive, exhaustive process where, at the end of this mandate, we could still be wondering what the whole outcome of it will be. I worry about that.

I will go on. Everyone on the Committee will have received a letter from Dr Sarah Cousins and Professor Max Watson. In it, they detail the efforts that they have made to try to get the Department to consider the individualised end-of-life care plans that are used in the rest of the United Kingdom. Why has that not been done?

Mr Cassidy: May I come back to your previous point? We were last here in January; it was not last autumn time. That is just for the clarity of the record. I accept that it has not gone as quickly as we would have hoped. However, we have a timeline, and it has been worth getting the engagement right to make sure that we have the scope of this right and that we have the broader range of professionals sighted in the understanding of what we are trying to do. However, it needs to proceed at pace, and it will.

There has been a lot of engagement on the individual end-of-life care plans. There are differing views about the most appropriate thing. Representatives have met with the Chief Medical Officer (CMO) in the past — I cannot remember whether it was 12 or 24 months — to discuss this issue. We are looking to progress that as part of the advance care planning and the recommended summary plan for emergency care and treatment (ReSPECT) form. We recognise that there is a need for standardisation as far as possible to make sure that people are getting an equal level of care. We are looking to advance that through advance care planning. The Committee had our colleagues here last week on that topic. When we are able to make progress on the advance care planning and draw up the standardisation of the ReSPECT process, it will deliver the same outcome as what is looked for in the individual care plan.

Mrs Dodds: My last word on that is that this letter clearly states that a draft plan was presented in 2019 representing all multidisciplinary professions. We are now in 2025. Is the assessment of palliative care in Northern Ireland going to drag on in the way that this has dragged on? This is not something that can wait for people. This was presented in 2019, and a response was received on 27 December 2023.

Mr Cassidy: The response said that the processes that are in place here are in line with the current National Institute for Health and Care Excellence (NICE) guidelines and that it was not intended to move away from that in the current time. As I said, the ReSPECT process, as part of advance care planning, is a way of getting the same outcome.

Mrs Dodds: Would you accept that, six years from when this was submitted, we are still no further forward in getting this, except that we have more process?

Mr Cassidy: A lot has happened in those intervening years, and, amongst other things, the advance care planning work really had its roots in COVID and the COVID response. It is material to understanding some of the delay in some of this work. I am not trying to make an excuse for it, but there are mitigating factors for some of this.

Mrs Dodds: Most of the COVID response finished in 2021. We stood up medical services that had been stood down at the end of 2020.

COVID, in my mind, is not an excuse not to do that. It is really important to do it.

I am really frustrated about the fact that something that is as important as end-of-life care has been put on the long finger by the Department for such a long time. Most people listening to the Committee today will be astounded to hear that that is how we are treating people in their most vulnerable moments.

That is it, Chair. Thank you.

Mr Donnelly: Gearóid, you mentioned the importance of keeping the record right. In your initial submission, you said that that would take six to nine months. I went back to the previous time that you came to the Committee. You are right; it was 16 January. On 16 January, you said:

Mr Cassidy: I am sorry for misspeaking. If I misquoted myself, that was a mistake on my part.

Mr Donnelly: Thank you. You also said:

Now that we have heard that the work will be completed in April or May 2026, by my counting, that is 15 or 16 months. You initially told us that it would be three to six months, then it was six to nine months and now it is 15 or 16 months. Has the work actually started?

Mr Cassidy: The work has started. I will put my hands up.

Mr Donnelly: Has the scoping exercise started officially?

Mr Cassidy: It has started in the sense that the programme board has been established and will meet in August.

Mr Donnelly: Has it not had its first meeting?

Mr Cassidy: The programme board has not had its first meeting. The meeting two or three weeks ago with the palliative care partnership board was about getting broad agreement on the project initiation document, which set out what we are trying to achieve and the workstreams. The next step is for the programme board to meet. In the interim, there has been a lot of engagement with stakeholders and providers to make sure that what we want to do is correct, we understand the evidence sources that would be available and how we make sure that we access the right evidence, as well as to secure some resources to take the work forward. Taking the work forward is really important, but it means that there are impacts on our capacity for other areas, and that has been part of the challenge.

Mr Kennedy: I am happy to pick up on some of that. The complexity of the scoping exercise has not been straightforward and neither has collaborating with our partners and managing some of the expectations. Something that is as simple as asking "Where do we start?" and "Where do we stop?", especially when we go to the general side, has been hugely challenging. We have purposely taken our time on that to a degree in order to stay close to the key stakeholders that will populate some of the task and finish groups. On key aim 2, we are progressing our procurement considerations, as Gearóid said, to potentially go to a third party to provide that hugely important piece of planning and commissioning work on our population's needs.

Mr Donnelly: Over the past couple of months, we have had some brilliant briefings from palliative care providers. We have met families and patients, and we have been to the hospices. We have got really good information since we last met you. I am not seeing any progress in this work. We were told that it would be three to six months, then six to nine months and now it is going to be 15 to 16 months. Is it realistic to say that the scoping work will be produced in that time?

Mr Cassidy: That is our current planning assumption. I was unrealistic, and in my initial comments to you I think that I said, "with a fair wind". I was not trying to be prescriptive by saying that it would take three to six months, but that was my sense of it. I was wrong in that.

Mr Donnelly: Are you realistic now?

Mr Cassidy: We have done more of the work now to bottom out what the workstreams and the evidence sources are, so yes, I think that it is more realistic.

Mr Donnelly: Just to go back, there is one thing that struck me. I think that you, Roger, talked about engaging with the sector and Hospice Alliance. Is that correct?

Mr Kennedy: Yes.

Mr Donnelly: You have not been able to get a cost for service delivery. Is that correct?

Mr Kennedy: Part of that engagement is about the uplifts to this year's contract and maintaining that 50:50 funding. We have regular contact with Hospice Alliance and Hospice UK, and I am grateful for that engagement. We have been open about what the cost of a general medicine bed looks like so that some of those conversations can be informed. As part of that, quite rightly, if there is concern about the existing, fairly long-standing general medicine planning assumptions, I would ask whether there is anything across these islands that could inform a reconsideration of same. I am to follow up in conversations with Hospice UK, but at the meeting that took place last week, no number was offered for a suitable alternative. I will follow up that engagement with Hospice UK and Hospice Alliance colleagues to tease out what exists across these islands.

Mr Donnelly: The number that you are talking about is the cost of service delivery. Is that correct?

Mr Kennedy: Of an inpatient bed.

Mr Donnelly: Of an inpatient bed; OK. We have visited hospices, talked to service providers and seen statistics, facts and figures. We have asked questions, and we have been given the answers, so I am surprised to hear that you have been unable to get that number from the providers. Are you asking the right questions?

Mr Kennedy: The question is quite straightforward in my mind. We are using x number of pounds, based on the cost of a general medical bed, through the SPPG patient level information and costing system (PLICS). If there is consternation about the planning assumption that we are using, what should the different number look like? I hope that I am asking the right question, and I am asking specialists, as part of a collaborative approach, to inform that.

Mr Donnelly: Have they not given you that number?

Mr Kennedy: I have had their individual numbers, if that makes sense, because the cost bases can look different across facilities.

Mr Donnelly: Individually, they have given you their numbers, so, have you had some numbers from them?

Mr Kennedy: I have had a figure for the difference between what it costs the local hospices and our planning assumption.

Mr Donnelly: You have had an answer, then, so you know how much the service delivery of an inpatient bed costs.

Mr Kennedy: That in itself is not enough for me to make a recommendation to change the cost base. For me to change the cost base, there would have to be a financial review and we would have to get into a service specification. That would involve the skill mix, the standard operating procedures in the multidisciplinary team and what we pay for. There is variation in what is provided through that skill mix. If it all looked the same, it would give us a standard cost, and that would require a financial review.

Mr Donnelly: Your plan is to do a full financial review. Is that what you are saying? You have had costs from those providers, including the hospice organisations here, but that is not enough for you, so you need to do a full financial review in order to qualify the answer.

Mr Kennedy: The last financial review was done in '19-'20. Sorry; 2019-2020.

Mr Donnelly: A hundred years ago.

Mr Kennedy: It was long ago, but not that long ago. Yes, I agree. There is probably something that we can take away and, on a timely basis, think about so that we can see what a new financial consideration would look like.

Mr Donnelly: I find it shocking that, in our visits, we have had presentations that have included figures on how much it costs to deliver the service. You just said that the hospices have given you figures, so you have had figures on what it costs them to deliver the service.

Mr Kennedy: There is a piece of work to be done to understand those individual figures to qualify —.

Mr Donnelly: Do you not understand them?

Mr Cassidy: I think that the missing piece in this is that we gave a commitment in 2022 that we would carry out a full review of specialist adult provision, which would, I guess, encompass not just a crude bed comparison but the full costs of a service. That work has not concluded, and it will be a full piece of work. It is one that, frankly, we have not been in a position to do, and that is why it has not progressed as originally planned. Roger and his team are engaging now to make sure that, while still using that same comparator of general medical beds, the value that is ascribed to it has been updated to reflect the growth in the cost base over recent years.

It is not the same as a full review that will maybe look at a different comparator — it is maybe a higher-cost comparator — but it is about making sure that the comparator that we use, which has been reviewed twice and was twice found to be appropriate, remains appropriate and has been properly uplifted to reflect the value of that growth base.

The Chairperson (Mr McGuigan): I am sorry to interrupt. I would like to be paying for a service today at the 2019 cost. I do not know of anything that has not gone up in price dramatically over the past six years.

Mr Kennedy: The 2019 cost profile has been uplifted over those intervening years due to, for example, Agenda for Change etc. The current process will look at a new cost base — that will potentially be a higher cost base — for this year. As part of that process, SPPG finance colleagues will engage with each hospice's finance lead individually to bottom that out. That may result in an increase in 2025-26.

Mr Donnelly: The scoping exercise has not started yet, but you have had the cost of service delivery from those organisations. The work that is, hopefully, about to get going will be about understanding that. Is that right?

Mr Kennedy: Yes.

Mr Donnelly: OK. Thank you.

The Chairperson (Mr McGuigan): Before we move on, let me say that I have a concern. It is maybe not a concern of the Committee, although I imagine that other members probably share it. Diane made the point that this is such an important service and that people cannot wait. The Health Minister gets £8·5 billion, which is a lot of money, and we want him to be very efficient with that money, but we also want good services and good patient outcomes. I do not want the Department, at any level, to look at services and then ask, "How can we save money or reduce costs?" and for that service to somehow be picked up by charities. I want the Department to ask, "How can we provide an excellent service for the people who genuinely need it?". It is important to make that point.

We have heard evidence from providers. For example, representatives from NI Hospice were here recently, and they provided a pretty detailed analysis of cost, including the cost comparisons, so it might be worthwhile looking at their evidence, along with all the other evidence on the costs that people from the palliative care sector have given us. I can categorically speak on behalf of the Committee and say that we think that the sector is not getting 50% of what it is entitled to and that we think that, actually, it should get more.

Mr Kennedy: Chair, I was at the Northern Ireland Hospice on Tuesday afternoon, and I walked through some of those numbers with Brian, who is the director of finance there. Any potential uplift in 2025-26 is taken in hand through the PLICS process in SPPG finance. For members' benefit, I will say that the contract will need to be uplifted with the Agenda for Change pay awards for 2025-26 as well.

Mrs Dillon: Chair, I apologise for being late. I was coming from another meeting, as was Nuala.

Chair, you kind of covered my question, and other members asked questions that were in my head as I was coming in. However, it is worth making this point again; it is based on what you just said, Chair. I understand that there was an uplift to deal with the cost of services and staff costs, including pay rises and all that, but I do not think that the staff in our hospitals would ever pretend to you that they deliver the kind of end-of-life service that a hospice delivers. We are talking about savings. Trauma is caused to families and loved ones when somebody does not have dignity in death. There is a significant cost to our health service in that, because it leaves significant trauma and leads to post-traumatic stress. That needs to be considered.

All the organisations that have been in front of us have given us very detailed information. There are some really good solutions. You do not need to look too far for solutions, because they have been presented to us, and, hopefully, we will be able to give you a report that will be helpful to you in any work that you carry out. I really hope that the Department and the Minister listen to that, because there are solutions. Some of them will potentially save the Department money, because there is potential for replication of services. However, the biggest issue, and members alluded to this, is the gaps that the charitable sector is picking up. The reason why the Department is having such difficulties scoping those services out is because they are not commissioned. The Department probably has no intention of commissioning them, and they have never been even considered for commissioning. However, they are very necessary and absolutely vital to the people who are in those circumstances and their families.

A lot of work needs to be done, but we, as a Committee, want to be helpful, and that is what the inquiry is about. We will certainly use our report to ensure that the Department can put in place the recommendations that come out of it. That is what we want to see. We want to see the best outcomes for people and their families.

Those are more points than anything. They have been well covered by other members, and I do not want to prolong the meeting, because I know that we have a substantial agenda.

Mr Robinson: Gearóid, a number of my colleagues mentioned timelines, and I am going to throw another into the mix. Contributors at a number of our sessions talked about fragmented services, one of which was specifically on Encompass. Will you tell us about that body of work, given that hospices have read-only access to that system? Going back to timelines, when do you expect that body of work to be completed? Do you have any information on when you expect that fragmentation with Encompass to end?

Mr Cassidy: Are you asking when hospices or providers will get full access to Encompass?

Mr Robinson: Yes.

Mr Cassidy: As you will be aware, Encompass has now been completely rolled out in all five health and social care trusts. The initial roll-out plan for Encompass was limited to those five trusts for a variety of reasons. Financial reasons were one, but operational capacity has meant that it has taken us a long time to get to this point. I think that there is a desire to extend roll-out to give full access to hospices and other providers. My understanding is that the hospices have been asked to make a combined — I do not know whether "bid" is the correct word — representation to the Encompass programme board about how that would happen. I do not have the detail of the status of that, and I am not aware that there is a current plan.

Mr Kennedy: Diane maybe touched on this at last week's meeting when we talked about the minimum dataset and the partnership with Encompass. Unfortunately, I cannot give you a timeline for that, but I am happy to come back to the Committee and confirm what it could be. That is being worked up, as I understand it, as a module of work with the Encompass team. Once that module of work is confirmed, a timeline should be attached to it, but I am happy to come back to the Committee to confirm that.

Mr Robinson: That would be helpful, because it would allow us to respond to those who asked those questions.

The Chairperson (Mr McGuigan): There is one last question from me, because nobody else has indicated that they would like to ask a question. I normally ask whoever gave the presentation what three things they think would make a difference. You are from the Department. We will make recommendations after the summer in a report, which we hope will, as Linda said, be helpful and acted upon. Are there things that the Department can do in the next six months in advance of the report and scoping exercise that will improve services for the people who need them?

Mr Cassidy: As Roger mentioned, engagement is under way on the funding level for the adult provision and on looking at uplifting it, although that is not being done through the full review. Making sure that hospices have the correct funding would be helpful in that space. Something that we have not talked about here — I touched on this in my opening remarks, and I am not sure whether you have had a chance to consider what is happening across the water with the 10-year plan — is the fact that we in the Department are very much looking at what a neighbourhood model for healthcare would look like for Northern Ireland. The permanent secretary gave you an outline of that when he was before the Committee a few weeks back. A key driver behind that neighbourhood model is delivering better outcomes for patients. It is also about helping to better manage care in communities away from hospitals, however, and palliative care has a really important role to play in that.

I do not think that you will see significant actions over the next six months that will improve palliative care services in that sense. However, in thinking about how a neighbourhood model will work and how regional or local assets will be deployed to best use in order to manage care better and make less use of hospitals, palliative care will be a really important element in preventing the need for care elsewhere. Those are the big things that are coming online, but we will not see a big difference over the next six months.

Mr Ryan Wilson (Department of Health): I have not come in yet. May I add a further reflection to that? I want to pick up on all that members said. As you come to reflect on your recommendations, there is something to be said about building on what is already in place. A scoping exercise will be done, and that will be a detailed piece of work. There is detail to come on the costings. A good job is being done in the collaboration between the palliative care partnership board and, on the paediatric side, the paediatric palliative care network. We fully acknowledge that there is a lot more to do. I think that you heard from clinicians last week as part of your inquiry about the complexity of delivering palliative care across all kinds of environments and parts of the health system and about the need for better education.

Those structures are in place, and they are doing a good job with what they have. I know that your recommendations will not result in new money coming into the system, but we would hold our hands up and say that, with greater capacity, the work could be done. The structures provide capacity in clinical leadership to do the work to develop regional pathways, promote collaboration across the system and the sectors, and promote that public health approach that I think that you heard about last week as well. The system is doing a bit of that and could do a lot more. That is not a criticism of anybody; I am just saying that the system is not doing nothing at the moment, waiting for other important pieces of work to be done. There are foundations and progress that can be built on and supported were more investment available to be put into them.

The Chairperson (Mr McGuigan): OK. Thank you very much. We appreciate that.