Should hospice care be part of the NHS?

Should hospices be an integrated partner with the NHS in their area? What are the advantages and disadvantages? Could it help with cost effectiveness for example or help with developing workplace opportunities and supporting a competitive career pathway?

These may seem to be surprising questions for anyone who isn’t acquainted with the hospice movement in this country. The NHS is so often referred to as ‘cradle to grave’ and it is widely assumed that hospices are part of the NHS, and therefore fully funded by the NHS.

There are over 220 hospice charities in the UK and a 2022 report from the Nuffield Trust and Hospice UK estimated that hospices support 300,000 people in the UK every year. That care is provided in inpatient beds, in day service settings and – in many cases – in patients’ homes and communities. Just like the NHS services.

In 2022 the requirement for the NHS in England to provide palliative and end of life care was enshrined in legislation. And NHS England’s own 2022 Commissioning and Investment Framework sets out clear responsibilities for every Integrated Commissioning Board (ICB) in relation to commissioning and funding palliative and end of life care.

In effect, hospice care is already part of the NHS - in Derbyshire there are three hospice charities and we are all active partners in the healthcare system locally. All three charities are already providing palliative and end of life care as described not only in the 2022 legislation, but also in guidelines from bodies such as the Royal College of GPs (RCGP) and NHS England itself. 

And yet the NHS funds, on average, less than 30% of the cost of all of the care that hospices provide. A recent analysis by Hospice UK estimated a shortfall of around £100 million in hospice funding for this year alone. Funding for end of life care in Derbyshire reflects that shortfall. 

Ashgate Hospice provides specialist palliative and end of life care in North Derbyshire; in South Derbyshire that same care is provided by an NHS hospice in a large acute trust. Both of us provide the range of services required by published NHS guidance. For the most part, on the ground, it works well. But the funding discrepancy is undeniable – this year, Ashgate will have to raise over £8 million to be able to care for the people who need us.

Like hospices nationwide we are actively involved with the local Integrated Care System including the Derbyshire End of Life Programme Board and various workstreams and partnerships. Ashgate works with Derbyshire Community Health Services, our local NHS community trust, to offer a programme of education and learning opportunities in palliative and end of life care which is popular with a range of staff across providers.

We are about to co-sign a workforce sharing agreement with the NHS and other providers in Derbyshire to enable staff to move between employers in the system without the need for things like DBS checks and the other processes that can complicate flexible working.  We have also been working with ICB partners to prototype a workforce experience app to provide wellbeing support and practical advice for staff and volunteers working in the Derbyshire healthcare system.

I often describe Ashgate Hospice as being in the NHS but not of the NHS – we are an independent charity, our services are regulated by the Care Quality Commission but most of the care we provide is funded by our local community’s fundraising efforts.

There is a need for an open, honest conversation about how hospice care is funded in this country – I would argue that’s the important discussion. The NHS has always worked with a plurality of providers – the most obvious example is GPs who have been independent practitioners since the beginning – so it’s not that there is an unsurmountable challenge in charities being part of the NHS provider landscape. And the current NHS guidance about palliative and end of life care is designed for a landscape that incorporates a range of provider models.

The conversation urgently needs to focus on the responsibilities set out in that guidance about what end of life care should be provided and funded in every ICB area. Nationally and locally, Hospice UK and its members hospices are campaigning for that discussion and for a clear commitment to recognising the gap in funding and transforming the model to ensure that there really is consistent and high quality care from ‘cradle to grave’ across the UK.  We need an honest dialogue and public commitments about the necessary steps to ensure that hospice care is no longer reliant on people running marathons and holding bake sales. 

In the meantime Ashgate Hospice, like every other charitable hospice in the UK, will continue to work with our local NHS partners to provide outstanding frontline care and to use our voice to influence local decisions about the delivery and funding of that care. And always with patients at the heart of all we do. 

Barbara-Anne Walker has been the Chief Executive of Ashgate Hospice in Derbyshire since 2017. Barbara-Anne has worked in the charity sector for over 30 years and has had an interest in palliative and end of life care since early in her career when she worked with people affected by HIV. 

Barbara-Anne led the national social care programme for Macmillan Cancer Support and previously worked as Operations Director with the British Red Cross. She was a Non-Executive Director of Derbyshire Community Health Services NHS Foundation Trust for eight years. In 2021 she was shortlisted for the Charity Times 'Leader of the Year' Award. 

Barbara-Anne is Scottish and Derbyshire has been her home for over 20 years.