Brian Davies / Guest specialist, Hospices

Developments in technology are playing a greater role within the wider health and social care sector. NHS connect, NHSnet and N3 are facilitating more efficient and effective communication between practitioners, enabling them to monitor and respond better to patients needs. However, there is a wide range of IT facilities and usage among independent and voluntary hospices and only a few have functioning links into NHSnet. Similarly, no single software package is recommended to record patient notes or episodes or used by the majority of independent hospices, NHS hospices or palliative-care units. Independent hospices will need to develop innovative and affordable IT solutions to enable them to compete effectively a competitive health market place and expectations that hospices will use major NHS technologies are likely to increase.

Hospices have a responsibility to understand and accept the procurement consequences of 'World Class Commissioning', the impact of user choice and plurality of provision. The patient is at the heart of care delivery and tenders will be used to ensure services meet identified needs. New skills will be required at leadership level to compete in this environment and deliver against this high impact area. As grants give way tariffs - PBR/full cost recovery as part of commissioning and procurement - hospices will face challenges locally. The local reality around commissioning of end of life services may not match the rhetoric of government.

The current recession will have a varying impact on independent charitable hospices. Some hospices will feel the pressure of the economic downturn more severely than others but there will be a noticeable effect on the funding streams for hospices. There has been a reduction in charitable giving that has affected the entire VCS including hospices. Independent charitable hospices will face specific challenges around residual legacies due to the uncertainty in the housing market. The recession may also present opportunties for hospices. The workforce pool for non-clinical staff will increase and financial imperatives may motivate hospices to recalibrate and streamline existing services and business practices.

Direct Payments and independent accounts will have a growing affect on independent hospices. The recent Health Bill included elements to allow the further development of ways to give patients greater personalisation and control over the health care services they receive by involving them directly in the commissioning of health services. Independent hospices may need to consider how this might impact on them. Will this change hospices relationships with the people they are caring for?

Independent charitable hospices will have to operate in an environment of increased demand/competition for decreasing levels of government funding, and this will have a particular impact on non-core services (as defined by government). This may accelerate a shift in focus of hospice services on to the clinical elements of specialist palliative care, a core NHS service, at the expense of other (i.e. social, psychological and spiritual) aspects of the holistic model of care independent hospices have traditionally provided. As potential funding for these ‘added value’ parts of hospice care becomes increasingly reliant on charitable donations, does your organisation need to think about targeting specific organisations and individuals for income to retain this holistic model?

The services provided by independent charitable hospices will be put under increased pressure due to an ageing population with a higher life expectancy but more years at the end of life spent in ill health. In the future more people will die old, disabled and demented. How well equipped are independent hospices to deal with the challenges of dementia and multiple morbidities?

Variations in the levels of income to individual independent charitable hospices from statutory and other sources will continue, but the majority of independent charitable hospices will most likely see some increase in the levels of funding they receive from statutory bodies as government takes a greater interest in the delivery of end of life care. Future funding arrangements between statutory bodies and independent charitable hospices will be contract based. However, statutory funding in the future will match delivery against agreed outcomes and it will also be important to use local communities to add value through voluntary giving. As grants give way to contracts, and possibly a national tariff, independent charitable hospices may need to be aware of the increasing expectation on them to deliver on commitments, and think about ways in which they can effectively respond to this expectation.

Increasing expectations amongst funders and the public will require independent charitable hospices to devise more sophisticated methods for collating and communicating information from families, service users and carers, and in demonstrating how they use this information to shape their services to what users want and need. This will also require independent hospices to understand best practice and learn from others. The end of life care quality markers currently being developed by the Department of Health and the commitment in the Health Bill to drive up the quality of health services through a duty to produce new quality accounts – means that hospices may need to improve how they asses the quality of the care they provide, and develop more robust methods of demonstrating evidence of the specific outcomes of hospice care. There continues to be a need for independent charitable hospices to generate evidence of the impact of the holistic care they provide to support national lobbying and local commissioning negotiations – specifically measuring the impact of ‘the place of care’, not just recording the ‘place of death’ will become increasingly important.

This driver is important for independent charitable hospices as there is a strong trend towards more personalised care at the end of life. Personalisation of care is a key policy feature of both the Department of Health’s End of Life Care Strategy and the end of life care visions produced by the individual Strategic Health Authorities in England as part of the NHS Next Stage Review. Personalised services and support for users to access a wider range of facilities will inevitably impact on staff. Independent hospices may need to ensure staff flexibility to work in different settings, to generate positive leadership and to empower at all levels. In the future independent hospices may have the opportunity to take a leadership role in developing new settings for care, new and appropriate educational links and curriculum design. Is your organisation ready for this opportunity? In what ways might an increase in personalised services impact on your staff?

Independent charitable hospices will be expected to be engaged in Local Service Partnerships, Local Area Agreements and related Voluntary and Community Sector structures, to share excellence, contribute to higher standards and take a significant role in the coordination of service delivery. Independent hospices will be increasingly expected to fulfil their potential within the End of Life Care Strategy framework and the end of life care visions developed by each Strategic Health Authority region as part of the NHS Next Stage Review. In many cases the success of relationships between independent hospices and Primary Care Trusts has relied substantially upon personal relationships between key players being constructive and effective, rather than any external guidance. Therefore independent hospices may need to look at ways to formalise existing arrangements, such as promoting the principles of the Compact with the Voluntary and Community Sector.

The Department of Health and local health and social care statutory agencies expect hospices to work within local networks to plan effective and appropriate End of Life Care services. As ‘Beacons of Excellence’ independent charitable hospices might look at exploring how they could influence standards of delivery within networks, support and challenge other delivery partners to activate agreed outcomes , and use existing excellence in service delivery, family support, bereavement services and so forth, in order to add value to local networks. The Health Bill announced by the Government in the 2009 Queens Speech enables primary care trusts to become more responsive to the needs of their local communities – what does this mean for hospices?. How might your organisation influence standards of delivery and demonstrate ‘added value’? In what ways could your organisation communicate local community needs to your primary care trust?

Independent charitable hospices need to consider that monopoly provision may well be a thing of the past. This may result in a stronger emphasis on improving delivery methods, productivity and reducing inequality of access. In future hospices may be measured on qualitative, performance and productivity indicators. How might your organisation deal with such future challenges? Are there any changes your organisation could make to your current performance indictors to help you respond to this change in the future?