Good morning and welcome to the Health and Sport Committee’s 24th meeting in 2015. I ask everyone in the room to switch off their mobile phones because they can interfere with the sound system. Some MSPs are using tablet devices instead of hard copies of the committee papers.
We have received apologies from Nanette Milne and Duncan McNeil; they cannot make it today.
The first item is a presentation by Professor David Clark on his report “International comparisons in palliative care provision: what can the indicators tell us?”. The report was commissioned by the committee and will inform our inquiry into palliative care.
Thank you for coming along this morning, Professor Clark. On behalf of the committee, I record our thanks for the hard work that you have put into the report. It is a substantial piece of work. In a moment, I will invite you to make a presentation to the committee for about 10 minutes. We would find that helpful.
As a small but important aside, I point out that your report got some media coverage this morning. Several members heard you on “Good Morning Scotland” so you had an early start. There is a positive and constructive dynamic about how we acknowledge good work that happens in palliative care, but we have not been afraid to tackle the gaps and drive forward change. We appreciate the work that you have done in pulling some of the statistics together. Thank you very much. I ask you to make your opening presentation.
Thank you for that welcome and your words of introduction. I am delighted to have the opportunity to present and introduce the report and answer questions on it this morning.
I begin in the same spirit as that in which you have begun, which is to build on some of the significant achievements in Scotland and on Scotland’s wider influence in the world of palliative care. I do not want to digress too much into a history lesson, but it is not widely known that the first ever home for the dying in the United Kingdom was established by a woman from Donside in Aberdeenshire, Frances Davidson, who moved to the east end of London and opened a home for the dying there in 1885.
During the 20th century, we have seen developments in hospice services in Scotland and the growth in interest in and influence of some of the major charities, particularly Marie Curie and Macmillan Cancer Support. We have also seen a key role in the formation of what we call the modern hospice movement, which sees hospice care as not just about the delivery of excellent care to people who are in need, but about education, research and wider engagement with society. I pay tribute to Dr Derek Doyle, who was the first medical director of St Columba’s Hospice in Edinburgh and who was instrumental in gaining recognition for palliative medicine as a medical specialty in Britain in the 1980s. He went on to be a major advocate for palliative care around the world.
There is quite a lot to celebrate about the contribution that Scotland has made to the field of palliative and hospice care, and about the resources that we have available to deliver care to people in our country. However, the situation in Scotland is quite different from that in the wider global context. Over time, I have tried to analyse the development of palliative care in all the countries of the world. As members will have seen in the report, we estimate that only 20 countries have an advanced level of palliative care development. We refer to things such as the availability of appropriate drugs for pain and symptom management, the provision of services in acute and community settings, the provision of education programmes, the existence of a body of research and, perhaps most important, underpinning policies and strategy on the part of Governments to support the development and delivery of palliative care.
Very few countries in the world are kitted out with those elements. Indeed, the World Health Organization very recently estimated that probably only 14 per cent of the world’s population who need palliative care get any access to it.
We live in changing times and we have to continue to review what we are doing, even in countries with well-developed palliative care. The key element of that discussion is that we are moving from hospice and palliative care being seen as the business of specialists of one sort or another—the people who have spearheaded the development of the field—to hospice, palliative and end-of-life care becoming everybody’s business. It is becoming more the business of generalists. In a wider context, there is a concern that we should all engage with it as an aspect of civil society and the wider society and communities in which we live.
It is time to take stock of where we have got to. There are lots of good things to acknowledge and celebrate, but we need to ask how much palliative care we are delivering and whether we are properly resourced to do that. My report tries to set out how we go about exploring that question and the indicators that we would need in order to provide some answers. Those indicators are to do with the supply of services, the need that those services are oriented to meet, the extent to which we have good access for and complete coverage of all those who need palliative care and, perhaps most critical and difficult of all, what we know about the outcomes of the care that is provided. How good is it? Is it appropriate? Is it well received by those to whom it is delivered? What is its quality?
My conclusion is that Scotland has problems in giving clear answers to such questions—and we are not alone in that—but I have tried to offer some solutions that we might explore in order to be better equipped to address those issues. When questions along the lines of “How good is palliative care in our country?” are quite reasonably put, we need to be better equipped to deliver fairly succinct but robust answers to them.
I recommend a number of things, on which I would be happy to elaborate. First, we need a reasonably robust mapping exercise of the delivery of specialist palliative care in Scotland. As I said in my report, we are unable to model palliative care delivery in Scotland against that in other countries because all the reporting takes place in a context in which Scottish data is buried within data for the United Kingdom as a whole. The time has come to create an atlas entry, if you like, that would allow us to compare palliative care in Scotland with palliative care in countries that have a similar population and are of a similar type.
The second thing worth doing would be to conduct a systematic review of the research on palliative care that has been done in Scotland, assess the research’s quality and get more lessons and action points out of it than we currently do. Such an exercise was done in Ireland recently. Good work is going on in our universities, some of which is not very well known. By systematically reviewing that work, we could do a lot more to learn from it and disseminate the results the more widely. It is not uncommon for a person who is involved in research in the field to be somewhat disappointed when they talk to people about work that they have done, which they thought was well known, and find that some of the intended audience is still unaware of it, through no fault of their own. A systematic review and a wide dissemination of the work that has been conducted in recent years would be extremely useful.
We also need more investment in measuring the ways in which we identify people who could benefit from palliative care. In my report I distinguish between the public health question of how many people need palliative care and the clinical question of how we identify those people when we are in front of them and referring them to appropriate services. As I have highlighted, colleagues here at the University of Edinburgh and in the Lothian region are developing a good measure—the supportive and palliative care indicators tool, or SPICT—but it is still at a relatively early stage of development. More work needs to be done on refining such measures to enable clinicians quickly and accurately to identify patients and families who would benefit from palliative care and could be referred to it, whether that is specialist care or care that can be provided by general physicians, general practitioners and the wider health and social care team.
Finally, we need to agree on the appropriate quality indicators that we would like to assess the robustness of palliative care of all stripes as it is delivered in Scotland, and we need to invest in measures that will allow us to gather the data to support those indicators and to disseminate them and learn from them.
Thank you, Professor Clark. I should have given your full title at the start. You are the Wellcome Trust investigator at the school of interdisciplinary studies, University of Glasgow. My apologies for not giving your full title.
The Dumfries campus, as we always like to say.
That is now on the record. Our first question is from Malcolm Chisholm.
Thank you for your report. I will start with definitions and numbers, and perhaps definitions have to come first. I suppose that a lot of people think of it as end-of-life care, but obviously palliative care has a different definition. In part, I wonder whether we have an agreed definition. Some people might say that the definition should be stretched to include care for those living with pain and chronic conditions, because people will always try to palliate pain and suffering. Is there a clear definition in the context of what we are talking about? Could it become so stretched that we would not be quite sure what we were talking about?
I did not want to muddy the waters too much on that, although it is an interest of mine. There are many definitions around—a recent systematic review of definitions of palliative care in English and German came up with 56 variants. I think that we would need some persuading to depart from the definitions of the WHO, which recently produced two definitions. However, there is an awareness that what we mean by palliative care is changing.
When hospice and palliative care first began to develop, the focus was very much on people with cancer who were at the end stage of their disease, when the trajectory was relatively short and fairly predictable. Hospice and palliative care came in at that point. Over the years, the WHO and many others have advocated for earlier intervention with palliative care and that is raising some complex debates, not least in the United States, where it is tied up with reimbursement issues. There is a strong argument among the palliative care leadership in the United States that we should drop all references to end-of-life care, death, dying or bereavement, and describe palliative care as an extra layer of support that helps people through the inevitable stresses, strains and challenges of their illness at all stages of the illness trajectory.
Here in Scotland and in the rest of the UK, we still see palliative care as closely associated with end-of-life care, and the broad reference point for end-of-life care is people in the last 12 months of their lives. As I have often said, it is often easier to say who those people are with the retrospectoscope than with any prospective approach, and we are challenged to know when people are in the last year of life and how best we can respond to them in that context.
There is no doubt that palliative care has a part to play at earlier stages of disease progression. As we age as a society and as people grow older and live longer, some of us will be challenged by multiple morbidities—not just cancer but other chronic conditions—and it is well accepted that palliative care has a role to play, as Malcolm Chisholm says, in the palliation of some of the problems associated with those conditions.
Your report gives estimates of the numbers. Is the main issue that services are not available or is it that people are not being identified? Related to that is the question whether there is a problem with general practitioner registers. Would we deal with the problem through more effective use of GP registers? How do we identify those who are not receiving the palliative and end-of-life care that they might benefit from?
09:30
The registers are a good start. Their character has been changing. We have had palliative care registers for some time and newer approaches have been introduced more recently. That is still at a fairly early stage. We have not yet done the studies—although some are under way—that would tell us whether those registers are reaching all the people who are in need. They seem to be quite effective at logging people with cancer and less effective for people with non-malignant conditions. In both cases, there is evidence that people are being registered only towards the end of their lives. We would like not only wider coverage but earlier registration.
This is an all-systems issue. We seek to raise awareness across the health and social care sector of the need to be vigilant in identifying people who have palliative care needs and might benefit from such care. As the committee may know, in 2014 I published a paper with colleagues in which we showed that, on any given day in Scotland, 29 per cent of all in-patients in hospital are in their last year of life and 9 per cent of all in-patients will die on that admission.
The point about that study is that it provides a wonderful opportunity for hospitals to think more actively about the identification of patients who are in their care and who unequivocally have end-of-life needs. However, we do not yet have simple measures to enable those people to be more readily identified at scale.
Let us say that we successfully identified all those people. What would be the way forward? You suggested in your opening statement that palliative care should be taken on board by a larger number of people, such as generalists. Is there scope for expanding what you might call the specialists—the people who work in hospices or in community teams around hospices? How would the unmet need be addressed?
I would like to do a proper modelling exercise of the specialist provision that we have, based on the guidelines of the European Association for Palliative Care. That would enable us to assess whether our specialist provision is more or less right. We would then have an evidence-based approach.
Whether or not that is the case, we certainly need to make palliative care more the business of a lot of other people. One difficulty has been that there is still perhaps a perception that palliative care comes in right at the end and involves giving up other things. The idea is that, if I pass my patient to palliative care services, I will lose my involvement with them and the opportunity to actively treat their disease.
As members probably know, that is exactly how hospice care is funded in America, although that is about to change. To go on to a hospice programme there, someone must have a prognosis of less than six months to live and they must give up all active treatment. That is not a desirable position—we would not want to see it here—but the mindset of some clinicians is perhaps still that there is a transition to palliative care that involves giving up certain things in order to access that care. We need to work on that right from the beginning with our medical students and nursing students. We need to promulgate more widely the idea that palliative care has an integrated role in the spectrum of care that we deliver to a person.
You talked about identifying those who are in receipt of or in need of palliative care. The committee is working on the Carers (Scotland) Bill, which has proposals for young carer statements and adult carer support plans. We are aware from our own family experiences that, as a person makes a transition towards palliative care, their family, friends and loved ones are actively involved in their care.
Legislation is going through Parliament that seeks to capture every individual in that caring process. Might that be an opportunity to identify those in society who are making a transition to palliative care? We will go on to talk about how we support people better. However, we have to identify those who need additional support before we can resource that support and provide it as best we can. Does that bill provide an opportunity to do that?
It definitely does. I have used rather medical language in talking about patients and their needs, but the key thing about palliative care is that it supports carers, families and others who are directly affected by the illness and impending death of a person and it seeks to assess their needs in delivering care.
The example that you just gave affords us an opportunity to seed thinking, language, ideas, information and evidence about palliative care across a spectrum of policy instruments, guidelines and statements from the Government. That is what we badly need.
Around the world, palliative care is still very much in an early advocacy stage, with people drawing attention to what it is and helping people to better understand it. The next step is to integrate those ideas more widely across health and social care systems. That means seeing such language in the documents that Governments issue.
The deputy convener went down the line that I was going to pursue. Before I continue on that line, I will address another issue.
Around 6.40 this morning, on “Good Morning Scotland”, you mentioned specialists and talked about a generalist approach. I would like to tease out a wee bit more about that approach, which includes the allied health professionals and, as the convener said, friends and family. When we took evidence on the Assisted Suicide (Scotland) Bill, it came out clearly that, culturally, we in Scotland do not face death well—we do not talk about dying or make provision for it. Is that a barrier?
That is an important issue, which the palliative care community in Scotland is doing excellent work to address. We have seen a number of examples of that in the past few years, such as the death on the fringe project; the good life, good death, good grief initiative; and the to absent friends festival. Those are all organised by the Scottish Partnership for Palliative Care.
That organisation and others, me included—I write regularly on a blog, and we run death cafes and the like—are trying to create a wider conversation across society about mortality and death. My experience of the death cafe phenomenon shows that it is remarkably easy to get people to talk about death, once we have brought them together and given them the opportunity. The notion that it is a taboo is quickly undone when we sit people down with a cup of coffee and an opportunity to talk about these things.
A great deal of work could be done on that. I would like a wider conversation to take place and our major institutions to take the issues more seriously. Universities, the business world and faith groups all have a significant part to play in a wider conversation about care at the end of life. They could also contribute to a discussion about the limits of medicine: what can we expect from our healthcare system and at what point do we acknowledge that the focus should be on palliation, comfort and dignity at the end of life? Those things are relatively intangible and somewhat difficult to measure, but they are not necessarily costly to deliver.
There is a pathway or journey towards palliative care across all ages. People move from requiring some care to requiring nursing care and then palliative care. In that transition, how do the families, the medical professionals and the allied health professionals identify when the patient requires palliative care?
A number of triggers can be identified, but they need to be put together and a conclusion needs to be reached. There are factors such as repeat admission to hospital; prolonged and unrelieved symptom difficulties or pain, even when the concurrent care for the condition appears to be optimal; and dwindling mood and a depressed affect. We can do many things, but the difficulty, particularly for families, is that these things can creep up on us slowly and are difficult to identify day by day. Nevertheless, the clinician’s role is to put such things together in a bundle and say, “Look, there’s a light flashing here. We need to think differently and have a conversation.”
You are absolutely right. Because they live with the situation 24/7, families tend to adjust and perhaps do not recognise the signs. Are you saying that it is down to clinicians to identify that the condition has moved forward on the journey towards the need for palliative care?
Clinicians are certainly key. In America, a lot of work is being carried out on an interesting model in which service users are being encouraged to self-monitor and then ask for palliative care.
Having mentioned aspects that we can attend to, I have to say that I was impressed with last year’s Reith lecturer, Atul Gawande, when he gave the key lecture at the Royal College of Physicians in Edinburgh last November. He talked about the simple questions that people should think about asking in this context, which include: what do you understand by your condition at the moment? What are the limits on the things that are acceptable to you? What would you most like to happen and what do you not want to happen? If those basic questions are put to someone, they will often result in good information. However, they are not routinely asked, and one notion is that such questions should be built into systems and asked as routinely as, say, the question whether a person is allergic to penicillin. The analogy that we should be thinking of those questions as routinely as we think about allergies is interesting.
Perhaps, Mr Robertson, you can ask one more follow-up question and then let other colleagues in.
Indeed, convener.
How important is such awareness for the health and social care agenda that we are moving into? In 2014, the World Health Assembly talked about the requirement for this to be an integral part of the services that all health boards provide.
Earlier you referred to the social dimensions. For most people, dying is not a medical but a social and personal event. However, although personal and social services are critical, they have tended not to be prominent in the dialogue about how we deliver end-of-life care.
The integration of health and social care provides a wonderful opportunity to address that more actively, to reduce inequalities, to promote equality and to build on the assets that exist in communities. I began by mentioning our assets in specialist palliative care, but we also have huge assets in our families and communities that we can build on if we properly support those who can give help.
09:45
I was interested in—and, in fact, disappointed by—your comment that we do not have the necessary data to fully understand the palliative care situation in Scotland. I am not sure whether that is because of an overall lack of data or an inability to disaggregate the data at Scottish level from the data at United Kingdom level.
You note in your report that you could not detect any significant correlation between the availability and quality of palliative care and inequality. There appears to be no difference between the availability of palliative care to those who are better off and its availability to those who are worse off in society, but have you noted any regional variation? A larger proportion of the Scottish population than of the UK population lives in rural areas, and I wonder whether there are particular problems in delivering palliative care in rural and remote rural areas. Do we have the data to know that?
This is a fairly weak answer, but we do not have the information. That is not because data cannot be got; it is because we have not committed to getting it, analysing it systematically and sifting it over time. That would not be too difficult a job to do, but we would need a commitment to do it and the resources to support that. I would like us to do that in order to build up a clearer picture of the quantity of palliative care—at the very least, of specialist palliative care—that is being delivered across the country as well as of the issues, if there are any, that arise in relation to access not only by where people live but according to their age, ethnicity and diagnosis. We need more robust data on all those areas if we are to properly understand how palliative care functions in Scotland.
Thank you very much. You have answered my questions.
I have a quick question on the data and information. It seems that the Scottish data is all wrapped up in the UK data and is hard to extrapolate. Why is that the case, given that we have had different health services since before the Scottish Parliament was created?
I do not know why that is the case. Some academics in Scotland are interested in the issue, but we do not have a Scottish network or a centre for palliative and end-of-life studies where those people could work together in a co-ordinated way and be resourced appropriately. We do not have an end-of-life observatory that routinely collates such information; we have a relatively small group of people who are doing studies. Many of those studies, important though they are, are based on small samples of local populations.
I have been arguing for a while that we need more population-based data on the need for palliative care in Scotland. I now have a role in assisting the Scottish Government to prepare its palliative and end-of-life care strategic framework for action, and the Government has identified measurement and data as a key issue for that framework to address.
There have been studies on the availability of palliative care for different conditions. Marie Curie published a report that said that people with cancer are much more likely to access palliative care than people with other conditions are towards the end of life. How can we make the system fairer, so that people with all conditions can access palliative care?
In my report, I hinted that the cancer and non-cancer distinction is becoming more blurred. Ten or 15 years ago, the contrast was quite stark, and most specialist palliative care services—then as now—dealt predominantly with people who had a cancer diagnosis.
For a time, people said that a cancer diagnosis was the passport to getting world-class palliative care and that those without it were excluded. However, cancer is changing—it is becoming a chronic illness. Someone might have cancer more than once in their life, and they might have other conditions as well. We should focus on the basket of conditions rather than on the cancer and non-cancer distinction. Particularly among older people, we have to link palliative care to issues of frailty as people live to advanced age.
It is generally accepted that some barriers to accessing palliative care still exist. The barriers also relate to age. Historically, palliative care has been better at responding to the needs of people with cancer in the slightly younger age groups. It has not been so effective at delivering care to people in advanced old age who might have had cancer but who might also have other problems, such as stroke, heart failure or orthopaedic problems.
There are lots of opportunities for geriatricians, orthopaedic surgeons and other services to be brought into the dialogue about their role in palliative care. In some of our hospitals, good work is going on where people are collaborating across specialties. We need to get a range and breadth of palliative care, rather than have a narrow focus of intervention.
Is the issue to do with patients being able to speak up for themselves? People with cancer who have a terminal diagnosis that is quite rapid can be in reasonably good health when they are discussing palliative care and can be demanding of those services. Elderly people, who might have had a much slower decline, and other people with illnesses in which the decline is much slower might be less able to ask for intervention when they need it and should have asked for it earlier.
That is right. Advocacy is an issue, which is why I have used the study that we did in Scotland’s hospitals as a platform for advocating for older people. We found in the study that not only do 28 to 29 per cent of all hospital in-patients die within a year but that figure rises steeply with age, particularly for men. More than 50 per cent of older men in hospital will die within a year, but they are not necessarily being advocated for or signposted for palliative care. That is where the involvement of other specialties becomes important, as well as the advocacy of the GP, the social worker and the nursing team.
Before I ask a question, I will say that I totally agree with Professor Clark’s comments about Dr Derek Doyle, who did remarkable work. I say that not just because I know of his work in St Columba’s Hospice and his work after that but because, prior to moving on, he was my GP. I am delighted that he is getting recognition here. He deserves it after his lifelong work in this field.
In replying to Rhoda Grant’s and Mike MacKenzie’s questions, you have talked about a lot of what I wanted to ask about. I will go back a bit. Cancer care is the most common and the most well-known form of palliative care; members of the public are aware of it. Slow degenerative illnesses seem to present a problem because of difficulties in going from ordinary care to palliative care—that depends on the speed of the individual’s decline—and because of the specialisms that are required to look after someone with, for example, Huntington’s disease or Parkinson’s disease. Is there a general way in which we look after people in palliative care, or are there differences that cause difficulties in providing the service throughout the country?
Some underlying principles are common across all conditions: good pain and symptom management, good assessment, regular and continuous review, multidisciplinary approaches that involve other colleagues and attention not just to the patient but to the family and the wider social context. All those general principles play out in any context. There are also condition-specific implications of the kind that you highlighted. One condition that you did not mention is dementia.
Although we were delighted that palliative medicine was recognised as a specialty in our country in 1987, perhaps it was a mistake to create a specialty with a full four-year training programme of its own. In other countries—most notably the USA—palliative medicine has become a sub-specialty of other medical specialisations.
When palliative medicine was recognised rather late in America as a specialty, it became a sub-specialty of about a dozen other fields. The idea was that someone first trained in paediatrics, geriatrics, orthopaedics, oncology or neurological conditions and then sub-specialised for a shorter period in the palliative care of people with those conditions. As a result, a body of knowledge and expertise is building up about the specific palliative care needs—as you indicated, they are sometimes complex and demanding—of those with particular diagnoses. Those specific care needs must be attended to by people who care for those patients in a specialist context and who practise the broader principles of palliative care.
The difficulty is that, over a long period, most of the focus has been on patients in the oncology setting with a diagnosis of cancer. We now have palliative medicine services that sub-specialise to a degree in looking after the groups that you described, but that is not the solution to meeting their needs. That solution comes from the specialist services that are already looking after them, which need to be more attuned to the palliative care approach.
I have one final question, which brings us back to where we started when we discussed the definition of palliative care and whether such care is part of the care specialist’s role or whether we all have a responsibility to offer a degree of palliative care, whether we are family or friends; care staff who come into the home to support someone’s social care needs; under-pressure care staff in a residential care setting who have to meet the variety of needs of frail elderly people, who might have additional multimorbidities; or staff in a nursing home.
I am trying to tease out whether, as the Scottish Government develops its palliative care strategy—you are assisting with that and the committee is conducting an inquiry into palliative care—you would encourage us to look at the full range of social care supports. If someone has trouble swallowing, a bit of help in eating might look like a social care support, but the chances are that the person could be in their last year of life, so it could be part of palliative care support. Would you urge us to broaden our inquiry or to focus on specialisms?
Definitely the latter. I have written about this elsewhere, although not in my report for the committee. There are two facets to palliative care. We have tended to dwell on one of them this morning—the view that it is a specialist medical service—but there is also the notion that it is everybody’s business as an issue in the wider sense of public health, as part of health promotion, community assets and community engagement.
We have a wonderful opportunity in Scottish society to promote more discussion and involvement in that. The questions could be addressed in the curriculum for excellence in our schools. We could engage on some of the issues with our young people and raise more awareness of end-of-life and palliative care needs across many of the subject areas that we teach in university. Employers could become more sensitised. Trade union members, faith groups and all kinds of community organisations also have a part to play.
There is a will on the part of some activists in palliative care in Scotland for there to be more engagement and for it to be recognised that, as the Scottish population age and grow, the solution to the issues will not be found simply in the formal healthcare system, because the issue is for the whole of society.
We are out of time but, given the nature of the discussion, I want to check that none of my MSP colleagues wants to ask a final question.
I will keep it brief, Professor Clark. You mentioned at the beginning work that is going on at the University of Edinburgh. Is that work being done on a tool that can be used to assess the need for palliative care?
10:00
That is exactly what it is. It is a relatively simple tool that can be used in a lot of contexts to identify people who might not necessarily benefit from specialist palliative care but who need greater attention to be given to their palliative care needs by those who are caring for them.
Will that tool be able to be used by all professionals, including medical professionals, allied health professionals and carers?
It could be developed in that way. However, I should point out the slight note of caution in my report. A tool called the Liverpool care pathway was developed and rolled out in England and many other countries but, because it was not well validated or robustly tested, it ran into major problems. We are eager for simple tools that can be widely adopted, but we need to invest time and energy in ensuring that they are robust, usable and reliable.
Was a tool used at NHS Grampian’s Roxburghe house by the consultant at the time, David Carroll, to measure more or less daily the patients who were in the hospice?
That tool would have been used with patients in a specialist setting. The interesting feature of the SPICT tool is that it identifies people wherever they are in the system.
Your report, presentation and answers to our questions will certainly help the committee with its on-going palliative care inquiry. Thank you for that and the work that you have carried out so far for the committee. I have no doubt that we will keep the dialogue and communication going.
I briefly suspend the meeting to allow us to set up for agenda item 2, which is a round-table evidence-taking session.
10:01 Meeting suspended.