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The end of life care challenge

The end of life care challenge


Meeting the end of life care needs for local people is a challenge that can be overcome by working closely with hospices

Hospices in the UK are among a small number of organisations that are both providers and funders of health and social care. They support around 360,000 terminally ill people and their family members each year and are also key funders of palliative and hospice care services, collectively spending more than £900m each year.

This dual role makes hospices ideal partners for commissioners to work more closely with, to jointly shape and develop services that meet the needs of people in their local communities.

Help the Hospices, which represents more than 200 hospices across the UK, recently undertook a survey of its members in England looking at how the NHS commissioning arrangements are affecting hospices.

The survey identified a number of significant challenges.

Unsurprisingly funding was a major issue, with a significant proportion of hospices experiencing frozen or reduced funding. Half of hospices surveyed reported their NHS statutory funding either cut or frozen this year, largely due to financial restrictions on NHS commissioners.

A further 18% of the hospices surveyed - that were still waiting to have their funding levels agreed for this year - said they expected funding to be cut or remain static. Hospices reported that the drop in statutory funding was having an adverse impact on inpatient care and home-based services. This included some hospices either having to reduce the number of slots available for hospice at home services, keep staff vacancies open longer to make savings or being forced to halt the expansion of services (such as a 24 hour advice line).

This year’s survey also found ongoing complications for hospices connected with the increasing complexity of commissioning arrangements. This was something that we identified as a concern in the commissioning survey we carried out last year. Our recent survey indicates that little has changed since then.

A third of hospices surveyed are now working with four or more commissioners. At the extreme end of the spectrum, one hospice reported having 25 statutory funding arrangements with 15 different commissioning bodies.

In addition, more than half of hospices surveyed (53%) said they faced increased costs to handle the additional bureaucracy involved in commissioning and contracting arrangements, or needed to dedicate extra staff time for this.

In many instances relationships between hospices and commissioners are improving according to our survey – 83% of hospices surveyed are engaged with their local clinical commissioning groups (CCGs).

However, our survey also highlighted lost opportunities for commissioners and hospices to work together.

Hospices described working with CCGs in a number of ways, but reported that commissioners were often being less positive about working with hospices as co-funding partners.

In addition, while the majority of hospices felt that their local CCGs have palliative and end of life care as a medium or high priority, almost a quarter felt that it is a low priority or not on the CCGs’ agendas. Further, only around a third of hospices (31%) were able to engage with local authority commissioners. 

Despite some of these challenges and shortcomings, encouragingly there is also growing evidence of closer collaboration between hospices and commissioners to find ways of working together that better reflect the relationship between the NHS and hospices as major funders of care.

A small but growing number of hospices reported they have entered into co-commissioning agreements with their NHS commissioners. In 2013, five hospices reported such agreements; that figure has increased to eight hospices this year.

One hospice has taken an even more active role in working with commissioners.

St Helena Hospice in Colchester has recently launched a joint commissioning relationship with North East Essex CCG (NEE CCG) for palliative and end of life care services in the region over the next three years.

It is believed to be the first arrangement of its kind in the country between a clinical commissioning group and a hospice. It marks recognition of St Helena Hospice as a lead provider in the community, as well as the significant voluntary sector funding contribution to local services.

The relationship aims to utilise the social value benefits of a joint NHS and voluntary sector-led approach to planning for, and meeting, increasing demand for non-acute end of life and palliative care services. 

Following our survey, our recommendations to commissioners include:

 - NHS and other statutory commissioners should seek to engage with hospices as key local partners in working to meet the needs of local communities. Hospices bring a unique combination of expertise, innovation, local engagement and resources to the partnership table. Their experience in partnership working to provide person-centred, co-ordinated care can help to make the best use of resources across sectors.

 - Commissioners should ensure that the levels of funding for hospice care reflect local need. The erosion of funding through ongoing freezing or cuts directly impacts on the ability of hospices to meet local needs. A focus by commissioners on the needs within communities and how best to meet those needs would help hospices and the NHS work together to address the growing need for palliative care.

 - Multi-year contracts and other funding arrangements, and earlier confirmation of funding should be put in place as soon as possible. Instability of funding impacts adversely on hospices’ ability to plan strategically and on confidence to make decisions about longer-term investment. Commissioners should be encouraged to introduce multiple year arrangements, and to confirm funding agreements as early as possible in the commissioning cycle to help secure sustainability and give hospices the confidence to invest further in developing services.

While many challenges clearly persist in the relationship between hospices and commissioners, our survey has highlighted compelling evidence that they can both work more closely together for the benefit of terminally ill people and their families in their local communities.

The challenge ahead is for commissioners to view hospices not solely as local charitable bodies - or ‘just another service provider’ - but as active partners with much to contribute towards improving care and outcomes for terminally people in their areas. 


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