BACKGROUND
In the UK, there is increasing pressure on third sector hospice services to demonstrate their value amidst considerable financial and economic austerity. With competition for limited statutory funding continuing to rise, it is necessary for hospices to demonstrate that they represent good value for money. Traditional economic evaluation methods such as cost-utility and cost-effectiveness analysis have frequently been used to evidence value; however, there has been a shift towards the use of alternative health economic measurement techniques [1]. In particular, the Social Return on Investment (SROI) methodology, which has the ability to account for wider socio-economic outcomes, thus ensuring a broader representation of value [2], has been promoted by the Cabinet Office [3]. In this KESS studentship, an evaluative SROI analysis of the inpatient and day therapy units of four North Wales hospice sites (A-D) was conducted to assess their social value.

METHODS
This thesis reports five empirical studies: I) a partial economic analysis was conducted through the application of a step-down costing methodology; II) a three-stage, mixed-studies, systematic literature review to determine the aspects of hospice care that patients and family-caregivers valued; III) a qualitative study using semi-structured interviews and focus groups was undertaken to explore stakeholder experiences, ascertain values, and identify outcomes to be used as quality indicators; IV) patient outcome data were collected via the Integrated Palliative Outcome Scale (IPOS); V) findings from the aforementioned studies were used to calculate the final SROI ratio.

FINDINGS
I) Due to structural differences in care models, the costs for Site D were calculated separately. The mean total cost of palliative care provision was £1,512,841 per year for Sites A–C and £1,034,927 per year for Site D. The average cost per patient admission to the inpatient unit was £446 (Sites A–C). The unit cost per at home visit was estimated as £190 per patient (Site D). The average cost per patient visit to the day therapy unit was £292 (Sites A–C) and £178 (Site D). Based on an occupancy rate of 80%, the mean unit cost for the inpatient unit and day therapy units was £407 and £169 respectively.
II) Thirty-four studies highlighted that an amalgamation of hospice service components were valued by patients and family-caregivers. These generally remained consistent across studies; however, the overarching synthesis demonstrated disparities between what people valued and why.
III) Seven principal outcomes were identified: improvements in relationships, physical and psychological symptomology, mobility, informedness, social isolation, and autonomy.
IV) Within the inpatient unit, ‘poor mobility’, ‘appetite loss’, and ‘weakness’ were recognised as prevalent issues. Psychosocial items of care were generally well managed although there was limited data pertaining to this. Within the day therapy unit, ‘breathlessness, ‘patient anxiety’, ‘family anxiety’, ‘weakness’, and ‘pain’ were identified as prevalent issues. In contrast to the inpatient unit, psychosocial items of care were often presented as severe.
V) The inpatient unit returned a base case ratio of £2.77:£1, whilst the day therapy unit returned a base case ratio of £11.85:£1.

CONCLUSION
Prior to this study, the SROI methodology had not previously been applied and completed within a palliative setting, and thus this thesis presents a novel approach. By taking this approach, important findings have been unearthed which have assisted in the construction of recommendations to guide future policy, practice, education, and research. As a result of substantial stakeholder involvement, these recommendations have been informed by stakeholder values and are thus representative of the population they seek to assist. Finally, the findings have emphasised the need for continued collaboration between academia and the third sector to generate and implement evidence-based practice.