Executive Summary
Palliative and end of life care in Wales
The growing number of elderly people resident in Wales, coupled with challenges within social care regarding recruitment and retainment of staff are placing increased supply and demand pressures on palliative care resources (Skills for Care, 2019; Welsh Government, 2017). Palliative care referrals increased significantly due to co-morbidities associated with COVID-19, and there have been calls for further investment by Welsh Government to address palliative care workforce issues (Bryer et al., 2022; Fenton et al., 2022; Rawlinson et al., 2021). There are various models of palliative care used in Wales, including hospice at home, hospice in-patient care and a combination of approaches (Luta et al., 2021; Mann et al., 2019).
In Wales, the End of Life Implementation Board (Welsh Government, 2017, 2021) has been set up to provide a national, one Wales approach to end of life care, providing leadership and peer support. The End of Life Implementation Board acts as a forum to drive forward change and oversee the efforts of Health Boards to deliver the Welsh Government vision of improving end of life care in Wales (Welsh Government, 2017).
Purpose of this report
This report provides a high-level analysis of reported income of hospices in Wales, together with illustrative case studies of providing hospice care for eight patients in North Wales. This report highlights the important role hospices have in providing care and reducing pressures on hospital resources in Wales.
Access to end of life care funding across Wales
Hospices in Wales have historically received public funding from a range of sources. Some hospices have clear commissioning arrangements or Service-Level Agreements with Health Boards that contribute to core services such as inpatient beds or hospice at home services, while others do not. Since 2008, there has been a level of funding provided to hospices across Wales through Welsh Government following the Sugar review (Sugar et al., 2008). This meant that some hospices were then in receipt of funding from both Local Health Boards and the Welsh Government, which made up their total funding. In 2016, The Welsh Government transferred responsibility for all funding to Health Boards under a ring-fenced arrangement.
Our objectives
1) To review the level of statutory funding for each adult hospice in Wales for the year 2019 (pre-COVID-19 pandemic), using publicly available accounts data from Companies House.
2) To calculate and forecast the number of hospice beds required in Wales in accordance with the Specialist Palliative Care Funding Formula for Wales (Finlay, 2009).
3) To compare and contrast the costs of end of life care for hospice service users through illustrative case studies obtained from work with Hosbis Dewi Sant and hospital end of life care costs in Wales.
Findings
There is variation in statutory funding between hospices across Wales. Statutory funding as a proportion of hospice care expenditure across Wales in 2019 ranged from 10% to 71%. Statutory funding as a proportion of hospice care expenditure in North Wales ranged from 15% to 19%, while in South Wales and Powys, the proportions ranged from 10% to 71%. The average statutory funding proportion across Wales was 30%. This highlighted a strong dependence on charitable donations to supplement the statutory income in those hospices not directly managed and financed by the NHS. Hospices in Wales can reduce pressures on public expenditure through their integrated financing models, as opposed to hospital-based end of life care fully funded by public funds through Local Health Boards.
Using the Specialist Palliative Care Funding Formula for Wales in conjunction with the latest Welsh population estimates, we calculated a current shortfall of 114 hospice beds in Wales (Finlay, 2009; Welsh Government, 2022b). Applying the formula indicates a current need for a total of 211 hospice beds in Wales. As of 2018, there were only 97 inpatient adult hospice beds in Wales (Hospice UK, 2018). This number does not account for children and young person hospice beds.
The cost of end of life care delivered by hospices and hospitals in Wales are presented through illustrative case studies for eight patients who received care in Hosbis Dewi Sant. The cost for a hospice patient staying for fourteen days ranged from £5,131 to £6,332, with a mean cost of £5,708 per patient. The cheapest hospital-based option in Betsi Cadwaladr University Health Board (BCUHB) for the same period was £6,860. Significant public expenditure savings can be achieved through increased utilisation of hospice-based care when considering the average statutory contribution to hospices is just 30%. With hospices contributing the other 70% of the cost of care through raising their own funds, ultimately reducing public expenditure through the co-funding model.
Recommendations
• Hospice funding should be reviewed in Wales, to better align funding allocations across Health Boards to reflect population density, urban and rural settings and any other services available.
• Based on efficiency and equity arguments, increase funding to provide the best support for complex case individuals with Palliative care needs.
• To explore patterns in patient preferences for end of life care and to configure services accordingly.
• End of life care needs to be well represented at Health Board level across all Health Boards in Wales. This would reflect better connectedness between acute care, social care and the third sector in Wales.
• Hospice staff are well placed to contribute to teaching future medical and nursing staff and students to support a better environment in hospitals at the end of life.
Future research
• Future research should investigate the quality of tailored end of life care in hospice services throughout the whole of Wales with an emphasis on cost-benefit to the wider society, including opportunity cost factors such as the impact on productivity of family carers in the wider economy.
• Collection of detailed costs for hospice and hospital-based end of life care would allow future economic analyses, including demand forecasting and the modelling of service provision.