Palliative Care Systems – International Comparison of the Czech Republic and Ireland – Lessons Drawing

Hospice and palliative care in the Czech Republic has been signifi cantly practice-oriented from the very beginning. Gradually, the professional specialisation of physicians and the professional education of general nurses was added. The growing awareness and interest of the professional and lay public, including political representation, brings the need to embed palliative care in the system of individual branches of social policy as a fully-fl edged part of this system. The aim here of comparing strategic documents and processes in the fi eld of palliative care in the Czech Republic and Ireland through an overview study is to contribute to the ‘lessons drawing’ for shaping the further development of palliative care in the Czech

In recent years, palliative care has received great attention in the Czech Republic, gaining its place in regional strategic documents, in the reimbursement mechanisms of public health insurance funds, and in legislation. Changes are oft en initiated 'from the bottom up' . Palliative care is essentially interdisciplinary care. Nevertheless, a number of changes take place in isolation in individual branches of social policy (health policy, education, social security). 1 Even if it is possible to follow partial eff orts, for example, at the regional level, the Czech Republic does not have a unifying vision and a strategy for its fulfi lment. Embedding palliative care as a systemic element in social policy, especially in health policy, can be seen as a process of large-scale change. It requires a shared vision of a number of actors, and the introduction of new elements into the system. Th ese are mainly new services, new expertise, new fi nancing tools. An integral part of the whole process is the setting of mutual relations between existing and new elements and the setting of related processes (transfer of information, fi nancial relations) and their anchoring in legislation, training, and practice. An integral part is also raising awareness and interest in new elements among the professional and lay public. In policy-making, 'lessons drawing' is a legitimate tool which is, in various intensities, obtained abroad. 2 Th e Czech-Irish study compares three basic areas: access 10 2020 to palliative care, strategic documents, and dominant players at the national level. Th e starting source was publicly available documents (policy papers, strategies, methodologies, profi les of organisations, see below) supplemented by semi-structured interviews with seven respondents. Th ey were identifi ed according to their profession (social workers, nurses, doctors, director) and type of organisation (in-patient hospice, hospital, umbrella institute, and provider of community palliative care). Th e basic areas of questioning regarded the system of palliative care, challenges in the development of palliative care, and advocacy. Th is study should be one of the contributions to the process of fi nding and creating a unifying vision and strategy of palliative care in the Czech Republic. With regard to the diversity of the environment (especially cultural-historical and legislative), it describes the similarities and formulates recommendations for transfer of experience at the level of 'inspiration' which are based on the diff erences found. Th e comparative study compares three basic areas: access to palliative care, strategic documents, and dominant players at the national level. Th e study was carried out within the programme of the Faculty of Humanities of Charles University Progres Q20 Kultura a společnost from August to December 2019.

Th e Concept of Palliative Care -TALKING ONE VOICE
Th e development of palliative care in the Czech Republic encounters the absence of a unifying vision, or rather the existence of more ideas about care for a person in need of palliative care and its form. Th is image is formed not only by the Ministry of Health, the Ministry of Labour and Social Aff airs, and individual regional authorities but also largely 'from the bottom up' by the providers and experts themselves who operate in associations or professional societies. Asociace poskytovatelů paliativní hospicové péče, Česká společnost paliativní péče, Česká společnost hospicové péče and Fórum mobilních hospiců are the main players in the development of palliative care in the Czech Republic. However, the direction of development is not uniform. 3 Th e Irish experience shows that the ability 'talking one voice' , that is, that most actors in a given segment know where they are going and what they want to achieve, allows more eff ective promotion of the interests of the group. Respondents mentioned in the interviews that a 2001 document 4 was used to unify the vision for the development of palliative care in Ireland. Th e content of this document became a 'bible' for providers and key players. It is important to mention that the unifying element was not the content of this document, but it was the process of its creation. Th is document is not only expert opinion on the development of palliative care but largely a written record of the negotiation process of a wide range of key actors, experts, professional societies and umbrella organisations. Representatives of hospices, hospitals, oncologists, general practitioners, ministries, and foundations worked in the commission that draft ed the document. Th anks to the broad support of this document among experts, it was subsequently adopted by the Irish Ministry of Health.
In its fi rst part, the document focuses on a general description of basic concepts, levels of care and the need for specialised palliative care. A large part of the document is focused on the development of specialised palliative care. Each chapter has clear, measurable, and suffi ciently specifi ed objectives. For example, Chapter 6.3 recommends that there should be at least one in-patient specialised palliative care unit 5 in each region 6 (note: the role of this unit is mostly performed by in-patient hospices). Chapter 5.5 specifi es that there should be at least one full-time palliative medicine doctor per 160,000 inhabitants. At the same time, the minimum of two such doctors in one region is set. Th e goals defi ned in this way enabled all representatives of key organisations to promote a shared vision not only because these goals were created together but also because they are concrete and based on the suffi cient specifi city of the defi ned recommendations.

Th e Four Pillars of Palliative Care
In Ireland, palliative care is provided in four settings -in the in-patient units of specialised palliative care, in hospitals (in the form of counselling), in the day-care centres of specialised palliative care, and in the home environment.
In-patient units of specialised palliative care (hospice)

Home environment Hospitals
Palliative care Day-care centres of specialised palliative care In-patient units of specialised palliative care are seen as an essential element of palliative care in every area. Th ey are oft en the coordinators of care in the region, including hospitals and local communities. Th ey work as a palliative care training centre for other health professionals in the region, usually providing expert advice and also conducting palliative care research. 7 In the Czech Republic, in-patient hospices are closest (considering the form and content) to these in-patient units of specialised palliative care. Th e coverage of these facilities in the Czech Republic is similar to that in Ireland. In 14 regions, we can fi nd 15 in-patient hospices, and two palliative care units in hospitals.
Palliative hospital care in Ireland is usually provided by a multidisciplinary counselling team that provides support to medical staff . Th e specialised palliative care team in Ireland consists of at least one doctor certifi ed in palliative medicine, a specialist nurse, a social worker, and an administrative worker. Th e team of specialised palliative care oft en shows other healthcare professionals in the facility good practice in working with seriously ill patients. It also oft en off ers education and training in palliative medicine in the area. Studies show that the introduction of a specialised palliative care team in hospitals leads to an improvement in the quality of care for patients with end-stage disease. 8 In the Czech Republic, counselling palliative care is a relatively new service provided in health care. Th e beginnings of its operation were supported by private foundations. 9 Currently, the Ministry of Health is implementing a pilot project 'Podpora paliativní péče -zvýšení dostupnosti zdravotních služeb v oblasti paliativní péče v nemocnicích akutní a následné péče' to support the establishment of counselling palliative teams in hospitals. As in Ireland, their task is to support and facilitate, for example, management of symptom burden, formulation of treatment goals, discussion about treatment alternatives, or management of diffi cult communication with the patient or his relatives (due to, for example, diverging expectations of therapeutic options) in the form of consultation, or supportive intervention. 10 In both countries, we can see that the ideas about the functioning of palliative care in hospitals do not diff er in content, however, we can trace a diff erent approach to the implementation of these changes. In the Czech Republic, short-term support has been created for a limited number of hospitals, although it is not yet clear what the care should look like in the future, how many hospitals will have a similar team, and whether its operation will be covered by health insurance. Th e Irish model points to a diff erent approach. First of all, they defi ned the target state -in each hospital, counselling services are provided by a specialised palliative team led by a doctor. 11 Staffi ng of the palliative team is given, and its members are at least one palliative doctor, palliative nurse, social worker, and administrative worker. 12 Day-care centres of specialised palliative care Day-care centres providing specialised palliative day care are an important pillar in the system of care for patients with serious illness in Ireland. Th ey are intended for patients who are not in the terminal phase of the disease and who are able to commute to the hospital (the service is, in most cases, connected to specialised palliative care units, i.e., hospices). Th is form of care is practically unknown in the Czech Republic. 13 According to zákon o sociálních službách (the Social Services Act), there are day-care centres providing 'out-patient services to people who have reduced self-suffi ciency due to age, chronic illness or disability' . 14 However, these services are not specialised palliative care. In order to fulfi l the Irish vision, it would be necessary to provide, in addition to social services, also health services, especially the availability of a palliator, a nurse, a physiotherapist, or other professionals. Counselling palliative teams can also play an important role here. Th ey could recommend these facilities to patients in the event of early intervention in a hospital environment. Th is type of service can be inspiring for existing Czech in-patient hospices.

Home environment
In Ireland, the GP is responsible for the medical care of his patients. He works with other health care providers, hospitals, and nursing homes, as well as with community-based palliative care providers. However, clinical responsibility for the patient in Ireland remains with the GP. Th e community specialised palliative care team recommends medication and other aspects of patient care but the decision to implement these proposals is at the discretion of the GP. Th is model is diff erent from the practice in the Czech Republic where the provider of mobile specialised palliative care is responsible for the care of patients (in the Czech context we are talking about home hospitalisation). Th e Czech model simplifi es the work of the MSPP provider 15 who is responsible for the quality of services and does not have to rely on the GP. At the same time, though, this approach creates tension between MSPP and GPs who oft en feel that the MSPP provider is intervening in their environment (this includes patients who are oft en accompanied by their GPs for a lifetime). In terms of the implementation of community palliative care, we could assume that the Irish model requires a higher degree of communication between subjects but it also increases the competencies of GPs (GPs can increase their competencies in caring for seriously ill patients when working with MSPP more closely). Th is model reduces the risk of confl ict between MSPP and GPs when transferring patients into MSPP exclusive care. In Ireland, similarly to the Czech Republic, community specialised care (or MSPP) services are provided oft en (but not exclusively) through teams which have been set up in existing specialised palliative care units (or in-patient hospices).
Th e organisation of specialised palliative care in Ireland relies primarily on counselling palliative care teams at hospitals and hospice centres which provide in-patient, out-patient and outreach care ('community care'). Cooperation in these services is, in many cases, facilitated by the simultaneous engagement of a palliative care doctor in all forms of palliative care service. Th e Irish model shows that specialised palliative care is primarily provided in two types of facilities -in an in-patient hospice providing palliative day-care centre and community palliative care services, and in hospitals with an established counselling palliative team. According to the respondents, the establishment of cooperation between these actors is an important element of the eff ective coordination of patient care. In Ireland, co-operation is usually supported in terms of staff (palliators working in hospitals also work in in-patient hospices) and spatially (in-patient hospices are usually built close to hospitals).

National Clinical Programme for Palliative Care
In 2010, the National Clinical Programme for Palliative Care was established in Ireland to ensure that patients with life-limiting illnesses and their families have easy access to palliative care suitable to their needs. Th e programme is coordinated by the national clinical leader, the national leader in nursing, and the programme leaders who work together to ensure that the programme's goals are met. In addition to this executive group, a multi-professional working group is also established to provide support to the executive committee in the process of programme implementation. Th e individual operational objectives are identifi ed in the document Report of the National Advisory Committee on Palliative Care. 16 In order to recapitulate the development of the implementation of palliative care in the health care system in Ireland, we should see two basic milestones: 1. Th e preparation of a document describing the desired target state (Report of the National Advisory Committee on Palliative Care) which was subsequently adopted by the Ministry of Health (2001) • pilot verifi cation and analysis of specialised palliative care operations provided in acute and aft ercare hospitals; • pilot verifi cation and analysis of reported home specialised palliative care; • proposal of indication criteria for palliative care in the case of relevant forms of palliative care; • quantifi cation of the patient population meeting the indication criteria for palliative care; • proposal of optimal and sustainable network capacity of providers of specialised palliative care; • analytical processing of available data and proposal of the optimal and sustainable capacity of the network of palliative care providers for patients aged 0-18; • possible recommendations for changes of a legislative nature which would be identifi ed on the basis of the analytical materials. 22 Th e role of the coordinator of this cooperation (according to a memorandum) belongs to ČSPM (Czech Society of Palliative Medicine). A comparison of the Irish and Czech systems shows a fundamentally diff erent approach to the implementation of palliative care into the system. In Ireland, experts created a shared vision (vision of the future state) which was subsequently implemented by the state -see the following fi gure:

Realisation of the vision by the ministry
In the Czech Republic, the model of piloting new services, collecting data and possibly securing funding from public health insurance funds is used. Th e Czech Society of Palliative Medicine has a coordinating and professional role.

Inclusion of the service in the payment decree
Th e Czech model can be perceived as very cautious, minimising the risk for health insurance companies and the Ministry of Health. Th ese need to make sure (by piloting services) that even in the Czech environment palliative services can prove their benefi ts for patients and cost-eff ectiveness (in spite of the fact that foreign experience has already proven this approach to be benefi cial for patients and for cost-eff ectiveness). Th is approach also brings great uncertainty for stakeholders: it is not clear in which direction the development of palliative care in the Czech Republic will go in the future. Although pilot projects may result in the setting up of funding for a given service, this is not guaranteed to providers of these pilot services. It is questionable whether the ČSPM's mandate in coordinating the development of palliative care is not too weak, and whether (according to the Irish model) there should be an executive committee at the Ministry of Foreign Aff airs responsible for implementing a comprehensive concept. Th is would then give providers some guarantee of stable development. documents between the Czech Republic and Ireland, one signifi cant diff erence is obvious. In the Czech Republic, the concept of two-stage palliative care prevails, that is, general palliative care and specialised palliative care. Illustrative examples of actors are assigned to individual levels (and inter-levels). 24 Ireland uses the concept of palliative care divided into three levels, which is currently also used by the European Association for Palliative Care (EAPC). 25 Th is is a palliative approach, general palliative care, and specialised palliative care. 26 Th e reason for the decision to use the two-stage model, which is also mentioned by the EAPC, may be 'simplicity' . Th is was valuable (from the point of view of ČSPM ČLS JEP 27 in the phase of establishing palliative care, especially in the health care system and health services. Th e three levels of palliative care as recommended by the EAPC defi ne these levels as follows:

Access to Palliative
• fi rst level -palliative approach -the principles of palliative care should be appropriately applied by all health professionals; • second level -general palliative care -the part of patients and families will benefi t from the expertise of health care professionals who are not engaged in palliative care full-time but have additional training and experience in palliative care; • third level -specialised palliative care -services of specialised palliative care whose main activity is limited to the provision of palliative care.
Th is structure is refl ected in the demands on the competencies of professionals in various helping professions. At the same time, it forms expectations from services and legitimate demands on various actors. Th e two-stage model off ers a clear structure for the medical professions, especially doctors. For other professions of the multidisciplinary team, the three-level model off ers a clearer space for application, for example, outside the medical fi elds -in social services, etc. 28 Th e advantages of the schematic division are manifested in the area of competencies. At the same time, it turns out that the emphasis on a palliative approach increases the probability of early involvement of palliative care (emphasis on the social worker's competencies is shown in the ability to use general and specialised palliative care by professionals as a source of support for caregivers at the fi rst level -i.e., counselling, training, advice, etc.). Th e Irish system emphasises the counselling concept of specialised palliative care. Th is concept assumes that one of the competencies of professionals operating at the level of palliative approach (or at the level of general palliative care) is that 'Th ey take into account the potential role of specialized palliative care services when supporting employees in other organizations. Th e aim is to ensure access to palliative care [at the level of palliative approach] for people with life-threatening illnesses. ' 29 Th is concept supports the availability of palliative care and, at the same time, it strengthens the eff ective use of specialised palliative care capacities. Such a concept precedes the perception of 'sharp interfaces' where the 'transfer of the patient/client' to the care of another professional, resp. subject takes place. Another element is, however, 'invited' into the spectrum of support and assistance services and professionals. Practice in the Czech Republic goes through the process of defi ning individual professions, services, and forms among themselves. However, the ensuring of higher availability of specialised palliative care can paradoxically cause more diffi cult access to routine health care. 30 Th e experience of palliative care providers at the palliative approach level 31 confi rms that the appropriate involvement of specialised palliative care in a counselling or shared care regime can be a highly eff ective way to ensure the availability of palliative care to a wide range of potential clients/patients. At the same time, it can contribute to the promotion of the concept of early palliative care. 32

Research, Organising, Advocacy 33
Palliative care is essentially multidisciplinary. Its holistic approach to human needs is refl ected in the demand for coordination and cooperation of a wide range of helping professions and helping lay people. Th ings which in practice have a positive eff ect on the quality of life of the client/patient place high demands on the coordination of other related processes -research, organisation of palliative care providers, administration, and eff orts to develop health and social care and security systems (advocacy). Th e coordination of these processes will ultimately aff ect the real availability of palliative care for the average person. To compare the environment of the Czech Republic and Ireland, the study focused on the institutionalised form of coordination, that is, the identifi cation of entities that are (according to strategic documents and testimonials) active in the comprehensive coordination and facilitation of the research process, the organisation of palliative care professionals, and systems administration and development. in research and to the need for inter-organisational and inter-sectoral cooperation. It acts as a facilitator for the development of palliative and hospice care in the fi eld of research and creates a space for connecting academics and educators, clinical experts, public administration staff and clients/patients and their relatives. It helps to create space for academic and applied research and supports the use of knowledge in everyday practice. A possible example of the results of the work is the document Palliative Care Competence Framework. 36 It defi nes the requirements for the competencies of employees of a wide range of professions (of those which are usually involved in the provision of palliative care). In the conditions of the Czech Republic, a similar entity is still lacking. An initiative of a similar nature is being developed by the Centrum paliativní péče (Palliative Care Centre), CPP. 37 A signifi cant diff erence between AIIHPC and CPP is in the scope of activities but, above all, in the way of governance of both organisations. Representatives of all partner organisations (universities, palliative care providers, hospitals, professional societies, etc.) are involved in the management of the AIIHPC. CPP is a young 38 non-profi t organisation that has a basic management structure based on the legal form of a registered institute. 39

Organising Professionals
Palliative care is based on multidisciplinary cooperation. Th e EAPC White Paper explicitly states that 'specialist palliative care services require a team approach, combining a multiprofessional team with an interdisciplinary mode of work. Team members must be highly qualifi ed and should have their main focus of work in palliative care. ' 40 Th e appropriate way of organising teams, the system of education, the way of managing organisations that provide services of specialised palliative care, is given, among other things, by the form of providing the service. Th e palliative team in the hospital environment focuses on other factors than the in-patient hospice team or the fi eld team. In addition to the internal environment of organisations and teams operating in the fi eld of specialised palliative care, the external environment plays a signifi cant role (legislation, funding systems, the system of education of future professionals, etc.). A suitable means for the development of organisations, good practices and for participation in the formation of the external environment is professional cooperation in the form of an umbrella network.
In Ireland, such an entity is the Irish Association for Palliative Care 41 which was established in 1993 and brings together palliative care professionals and is a collective representative of the interests and needs of members at national and international level, with a number of permanent or ad hoc groups and committees. Th e unifying element is the topic of palliative care. Th e organisation complements the activities of other professional groups and associations.
In the Czech Republic, the situation is less clear. Th e agenda is scattered among several subjectsthe Czech Society of Palliative Medicine of the Czech Medical Society of Jan Evangelista Purkyně (ČSPM, founded in 2008) 42 and its specialised sections and working groups that bring together professionals in palliative care. Other entities are organisations that bring together mainly 2020 organisations providing palliative care services, namely Asociace poskytovatelů hospicové paliativní péče (the Association of Hospice Palliative Care Providers, founded in 2005) and Fórum mobilních hospiců (the Forum of Mobile Hospices, founded in 2017). Internal inconsistency manifests itself both within the Czech Republic and in international cooperation. 43 Advocacy Th e development of palliative care is closely linked to state policy in the areas of social security and services, health, and education. Individuals across the palliative care spectrum oft en make eff orts to infl uence this policy at the local level, some at national level, some have an ad hoc initiative, others work on a long-term basis. A comprehensive mapping of the establishment of palliative care in the system of services and its comparison in Ireland and the Czech Republic goes beyond the scope of this text. At present, the environment diff ers mainly in the direction of developed initiatives. While in Ireland it is possible to trace the 'top-down' direction, in the Czech Republic 'bottom-up' initiatives predominate. Th e already mentioned Report of the National Advisory Committee on Palliative Care 44 in the introductory part emphasises the contribution of civil society to the development of palliative care which is followed by further eff orts. It does not merely regard a kind of historical delay. It is not just about state policy, its acceptation of the institutes, tools and 'good practice' (which were created so far as a stable part of the system), and its further support of the development of existing and new tools, elements and methods. It is, amongst other things, about the fundamentally diff erent legal systems of Ireland and the Czech Republic 45 which have a direct impact on the success of 'advocacy' strategies. Nevertheless, it is possible to be inspired here as well, especially in the area of non-legislative goals and procedures. Until now, initiatives that initiated a change in the legislative environment (for example, the enactment of hospice care in 2017) have been considered successful 'advocacy' strategies in the fi eld of palliative care in the Czech Republic. 46 Partial legislative changes without a broader systemic context and without a link to the unifying vision may raise concerns or opposition of another part of the professional public (cf. confl icting opinion on the abovementioned legislative change prepared for ČSPM ČLS JEP). 47 In the Czech Republic, it has not yet been possible to obtain key actors for the topic of palliative care which would form a longer-term strategy in the fi eld of health and social security, and to create an environment for systematic work based on data, negotiation, and involvement of key actors at the micro, mezzo, and macro levels. In the draft strategic document Zdraví 2030 (Health 2030), 48 palliative care is mentioned to a limited extent, mainly as a set of measures (types of services, capacities, etc.). Th e change in the conditions for the development of palliative care is not only in their quantitative strengthening, legislative regulation, or the volume of fi nancial resources. Th is is explicitly stated by Dr Tony O'Brien, Chairman of the National Advisory Committee: '… Over the years to come, the success or failure of this report will not be judged solely by the number or diversity of our specialist palliative care programmes, nor by any set of pre-determined statistics documenting our activities. Th e success of this report will be judged by the extent to which we all learn to recognise and respond to the complex and challenging needs of our palliative care patients and their families. For the future, I hope that this report will ensure that all health boards are in a position to provide a level and a quality of service that both refl ects and defi nes best international practice. Our patients and their families require and deserve nothing less. ' 49 It can therefore be concluded that without a change in attitudes towards the advocacy process, without a shared vision and clear goals, not only it will not be possible to use synergies to push for change but the eff orts of part of the professional spectrum may, on the contrary, be weakened or exhausted by the eff orts of another part.
Success in 'advocacy' is determined, among other things, by the involvement of the necessary resources -networks of contacts, people, information, and fi nance. When monitoring the origin of a number of current strategic initiatives and system documents, it was possible to trace an entity in Ireland and one in the Czech Republic which gave support to many of them during their creation. In Ireland, it is the Irish Hospice Foundation. 50 In the Czech Republic, Nadační fond AVAST (the AVAST Endowment Fund) can be described as a similar entity. 51 A common feature for both entities is that they are not palliative care providers themselves, nor are they professional associations. In both cases, the primary instrument of infl uence is fi nancial support for initiatives with the potential for a signifi cant impact on palliative care, that is, the development of palliative care and changes in public policies in connection with relevant fi ndings, research results, and pilot verifi cation. Th e Irish Hospice Foundation is a body which was set up for this purpose. Th e programme is run by representatives of the professional community. It is a foundation, that is, an entity designated for 'permanent service of socially or economically useful purpose' . 52 Its purpose was specifi ed by the founder. Th e Irish Hospice Foundation thus supports projects based on a broader consensus of the professional public. Th e AVAST Endowment Fund is a corporate endowment fund, and its administration is in the hands of the founding corporation. Th is has a right to appoint a board of directors -the fund's statutory body. Th ere is also a signifi cant diff erence in the way of obtaining fi nancial resources, which are subsequently distributed by these entities. In addition to the revenues from the foundation's assets, the Irish Hospice Foundation actively raises funds in the public space. In this way, it contributes to the strengthening of awareness and interest in the topic of palliative care. In some cases, though, it also competes in the process of attracting donors with other entities (e.g., palliative care providers). Th e AVAST Endowment Fund distributes fi nancial resources given by the founding corporation. Considering the state of development of palliative care in the Czech Republic (newly emerging providers, insuffi cient legislative entrenchment of palliative care services, etc.), it can be said that the current form and volume of support represents an extremely important impetus for the development of the whole fi eld in the Czech Republic. Despite these diff erences, the two entities use highly participatory techniques and procedures to identify topics suitable for support. 53 49 © NAC, Report…, p. 5. 50 © Irish Hospice Foundation -https://hospicefoundation.ie. 51 © Nadační fond AVAST -https://nadacnifond.avast.cz/index. 52 Act No. 89/2012 Coll., občanský zákoník, §306 (Civil Code, §306). 53 Over the past 5 years, NF AVAST (the AVAST Endowment Fund) has invested over CZK 150 million in supporting the development

Summary
When comparing the systems of the Czech Republic and Ireland, it is possible to fi nd a number of parallels and, at the same time, one can obtain great inspiration. For a number of reasons (e.g., diff erent legal environments) it is not possible to just copy individual steps. It is possible to be inspired in many ways. Th e comparison itself and the eff ort to understand the described diff erences can serve for the development of the whole fi eld. Th e embedded table captures diff erent viewing angles when comparing systems. Approach to the development of palliative care From shared vision through goals to realisation: Shared vision -goalsstrategy -implementation of system tools -development of services and system elements From partial visions and practice to legislation: Partial visions -experiments and pilots -integration into the system of palliative care in the Czech Republic. It uses participatory techniques to a large extent in the preparation of programmes and in the selection of supported activity projects.