How will you prioritise your care?

In a recent interview with Hospice UK, Dame Cicely Saunders biographer David Clark ‘recalls Cicely reflecting on the issues hospices were beginning to face. She would often tell him that she’d had ‘the golden years, when everything was expanding’.

Some 20 years since she died, Cicely’s comments seem very prescient. Recent months have seen several hospices make large reductions in services for financial reasons. And others may soon have to follow suit. 

Like all charities, hospices have obviously always had to choose how they allocate their charitable spend. The graphic above aims to show what this may look like in practice. 

This maps different options in terms of numbers impacted against the ‘distance’ of the hospice’s involvement in achieving that impact. The size of the boxes indicates respective share of charitable spend. No doubt there are differing views on the exact placing of each option, but hopefully it makes sense as a model.

Moreover, a hospice also has choices of how much to spend on different types of service delivery. Joe Saxton talks about how a hospice might map services against three variables. (i) The total number needing support, (ii) The numbers an option could reach and(iii) The ‘success percentage’ of each option. 

The aforementioned article also says that Dame Cicely chose to set up St Christopher’s to ‘give her the freedom to explore and develop new methods of care outside the confines of existing healthcare policies.’

In keeping with this spirit, hospices have develop services in many ways; the ‘beyond cancer’ agenda, more support for carers, accessing ‘hard to reach’ groups, supporting people earlier in their illness, etc. The emergence of children’s hospices is another example. 

The fact that until recently the sector has always recorded a collective surplus provides some justification for this approach. Indeed, coming out of the pandemic, most hospices had stronger balance sheets than ever before. 

But for many that picture has changed drastically in the last few years. So, in the current environment an aim to ‘do more, for more’ no longer seems viable.  

Does the sector instead need to focus its charitable spend on where it can make the most difference, on where the most acute need is? If so, how can this be ascertained? Presumably it will differ from one area to the next, depending upon the extent of services provided by the NHS and others.

And what impact might public opinion have? In 2014 Pilgrims Hospices decided to close their Canterbury unit and focus on community services as this meant they could support more patients. But what made sense in the boardroom, did not in the world outside and a huge outcry forced a change of mind. 

In 2005, Cicely’s biographer David Clark edited and co-wrote ‘A Bit of Heaven for the few? An oral history of the hospice movement in the United Kingdom.’  In an ever more difficult world, the challenge inherent in the title will become more and more acute.

But how do hospices decide what is the ‘core’ of the services they provide and the balance between need, resources and impact? 

There are no easy answers. But for many, the question is becoming more pressing. 

Difficult as it is, surely it’s best to start considering this well before you actually have to decide?