A “broken” end-of-life care system is creaking at the seams, hospice nurse leaders have warned, as redundancies, bed closures and multi-million-pound budget deficits are taking their toll.
Hospice UK has estimated that hospices across the UK are facing a £77m deficit for the 2023-24 financial year, and that, without help from the government, this will not go away any time soon.
“The current financial model for hospices is just not fit for purpose”
Leon Ratcliffe
Driving this financial crisis are surging costs from staffing – which makes up around 70% of a hospice’s budget – as well as utility bills and other expenditures.
The shortfall means hospices have been forced to take the paradoxical step of making nurses redundant despite growing demand for their services.
There have been at least 175 staff redundancies in five hospices across the UK in recent months, including sites in the East and West Midlands, London and South East England, Nursing Times understands. Staff made redundant include registered nurses, nursing support workers and other clinical and non-clinical staff.
Senior nurses at two palliative care organisations which have been forced to lay off staff due to funding difficulties, St Giles Hospice in Lichfield and Birmingham Hospice, told Nursing Times of their frustration at the current funding arrangement, and the impact it is having on their local communities.
St Giles’ deputy director of clinical services, and registered nurse, Leon Ratcliffe, said his hospice was grappling with a £1.5m annual shortfall following a drop in central government funding.
The hospice, earlier this year, announced it would cut 40 full-time equivalent (FTE) posts, including some nurses, to stay afloat – as well potentially closing some of its 23 beds. “It’s shocking… when families need our specialist support and all that comes with it,” said Mr Ratcliffe.
State funding of hospices is decided by integrated care systems (ICSs). However, the amount an ICS can allocate for local hospice organisations depends on the amount of funding provided by the UK Government.
Leon Ratcliffe
Hospices receive, on average, around a third of their funding from the government, with the rest accounted for by donations, charity shops, bequests and other arrangements, according to parliament figures.
This figure is lower in some settings than others, however; Mr Ratcliffe said that government funding accounted for 17.7% of St Giles’ overall income, down from 25% in previous years.
“The current financial model for hospices is just not fit for purpose,” he continued. “There needs to be a review of that funding model to reflect the care that we deliver.
“It’s why we’re seeing hospices across the UK struggling… this is a massive problem, [and] if it’s not addressed then the volume of patients that hospices can see is going to decrease.”
This sentiment was shared by Kerry Millard, deputy director of clinical services at Birmingham Hospice and a registered nurse.
Her hospice, which runs two sites across the city, is facing a £2.4m budget deficit and is making 45 FTE staff, including some nurses, redundant as a result – totalling around 14% of the organisation’s total workforce.
Ms Millard, who was formerly a district nurse, said a significant problem many hospices faced was the lack of funding for staff pay rises.
Hospice nurses are not on Agenda for Change contracts because they are not employed by the NHS. Most hospices try to offer their staff equivalent wages, but state funding does not always increase in line with a new pay offer.
A spokesperson for the Department of Health and Social Care (DHSC) told Nursing Times that new NHS guidance “advises” how contracts between ICSs and hospices should be “updated” to fund pay awards.
“There is a huge need out there for personalised, compassionate end-of-life care that we can give, and yet we are having to reduce services”
Kerry Millard
Ms Millard explained that, in some cases, hospices that had been forced to reduce staff were also at risk of losing nurses due to their inability to fund competitive salaries.
“There are so many amazing nurses who really want to specialise in palliative and end-of-life care, but with the cost of living the way it is – if you are going to then have to take a pay cut, you have to weigh it up.”
She described a postcode lottery in which some regions, like hers, had hospices so stretched that many people would not get palliative care in a specialist facility, even if they wanted or needed it. “We know 100% of people are going to die,” she added.
“It’s the one thing that we’re certain about in life. We know we’ve got an ageing population.
“We know that there is a huge need out there for personalised, compassionate end-of-life care that we can give, and yet we are having to reduce services and that has such a huge effect on our communities and the people that we’re able to reach.”
She added: “As a nurse, that is devastating. It’s devastating for our staff who feel that they’re not able to reach the number of people that we have been able to [in the past].”
Even those at larger hospices are starting to worry. Amanda Mayo, care director at St Christopher’s Hospice and a registered nurse, said it felt like palliative care had been deprioritised in the eyes of the government.
St Christopher’s runs five sites across London, caring for around 1,800 people, with dozens of nurses at its inpatient facilities. Ms Mayo said a recent uplift from the local ICS was not enough to cover the cost of matching the 5.5% nurse pay rise received by Agenda for Change staff in 2023-24.
Amanda Mayo
“[ICSs] are doing cradle to grave, neonates through to specialist palliative care and they’ve got to divide their funds up – it’s an unenviable task, isn’t it?” she said, questioning why the government does not fund 100% of the basic NHS care, such as running the inpatient beds, and then leave hospices to self-fund extras St Christopher’s runs like music therapy, a café and other amenities for families.
“I have 27 patients today up on my ward, and there’s no one there who does not need to be there,” Ms Mayo added. “They’re all receiving nursing and medical care.”
Susan Hogston, head of nursing and quality for the Marie Curie Hospice in Bradford, West Yorkshire, spoke about the importance of the hospice she works at for the local area.
“[They are] fabulous places, I think we’re a real jewel in the crown in Bradford and we do so much more than just the inpatient beds,” she said.
“That ability to connect with the community, to build long-term relationships and to get people talking about death and dying is really important.
“When people say: ‘If I die…’, well, it’s never an ‘if’, it’s always a ‘when’ and actually supporting people to have a good death is important… living well until you die is important.”
Ms Hogston said that donations were keeping the sector afloat, but that in more deprived areas the cost-of-living crisis made this an unreliable source of income.
“Bradford is in an area of high deprivation,” she said.
“We’re part of national charity and we’re really well supported across Yorkshire, [so] that makes a big difference to us.
“But if you’re a small, independent hospice, the cost-of-living crisis is affecting every single household in the country… for some, their donations have really taken a hit in recent years.”
She echoed what the other nurses said: that without a change to the funding arrangement, more nurses will be lost from hospices as charities are forced to make savings.
According to data from Hospice UK, in the 2023-24 financial year hospices in England received around £504m in funding from charity shops. This was greater than the £466m the UK Government gave to hospices in the same year.
Sarah West
Hospice UK director of external affairs Sarah West said this figure was a damning indictment of the current funding arrangement.
“People are funding our end-of-life care by buying jeans and t-shirts… I don’t think that’s acceptable on any level,” said Ms West, who described stagnant government funding and the recent Agenda for Change pay rise as a “perfect storm”.
Ms West said, however, that the government had started to listen.
“I think that economic work is being done behind the scenes to look at [it],” she said.
“But it doesn’t need huge amounts of detail to see that if you can prevent someone who may be a year or two away from the end of their life from moving into hospital, and then bouncing between there and their home, it doesn’t make financial sense when the NHS is creaking at the seams.”
“The fact is, at the moment, end-of-life care is broken… we have to get this service right, it’s imperative”
Paulette Hamilton
What precisely a good funding arrangement would look like, Ms West said, differs between hospices.
However, she was clear that the current model was unsustainable, with the potential for sites to further reduce staff, or for an “exodus” of nurses out of hospices because of a lack of funding for a pay rise.
The pleas for help by hospice nurses have a signal booster in parliament in the form of Birmingham Erdington MP and former community nurse Paulette Hamilton.
As a representative of both the nursing profession and a constituency containing hospices that have had to make staff redundant due to budget pressures, Ms Hamilton has promised to fight for a better deal for the sector.
Both before and after the general election, the Labour Party has emphasised the need to shift the NHS’ priorities from treating illness to preventing it. Ms Hamilton welcomed this, but felt that, at present, this focus meant areas of like end-of-life care were at risk of neglect.
Paulette Hamilton
She has written to health and social care secretary Wes Streeting and care minister Stephen Kinnock demanding action.
“The issue I’ve had is that [the government] wants to concentrate particularly on prevention,” said Ms Hamilton.
“But, my argument is that at some point in time we’re all going to get to palliative care. The fact is, at the moment, end-of-life care is broken… we have to get this service right, it’s imperative.”
She said that, unfortunately, palliative care was not a “sexy” subject for policymakers, and one which was easy to “brush under the carpet”.
However, Ms Hamilton said: “I was a district nurse for many years, and I know that although somebody may be in that part of their life, that third part of their life, they’re still living and I want them to have a high-quality standard of living.”
The Labour MP criticised her government for a lack of a “clear” policy on reform to palliative care going forward, and warned that things could get worse for the hospice sector if no one stepped in soon.
She added that she hoped to lead a future all-party parliamentary group on the hospice sector to keep banging the drum for palliative care.
A spokesperson for the DHSC told Nursing Times: “This government has inherited huge challenges in the hospice sector, as well as a £22bn black hole in the public finances.
“While most end-of-life care is provided by the NHS, we recognise the vital role hospices play in providing support to people at [the] end of life and their families.
“We are determined to shift more healthcare out of hospitals and into the community, to ensure patients and their families receive personalised care in the most appropriate setting, and hospices will have a big role to play in that shift.”
More on the funding crisis in hospices
