Alot of charity has gone a long way in the UK's independent hospice movement. Over the last three decades it has drawn primarily on the financial generosity of individuals and charities to provide essent ial healthcare to hundreds of thousands of gravely ill and dying patients.
The NHS has been happy to make increasing use of hospice services, but the days of it getting their services on the cheap could be over.Many hospices are in financial crisis, and for the NHS, this could be payback time.
Hospices have called for a£150m cash injection from the NHS to help stave off the crisis. Without this money, they say there will be widespread cuts in palliative care - cuts which could seriously impact on key parts of the government's NHS plan.
They will warn in a report due to be published in the autumn that if the financial strains on the hospice movement do not ease, palliative care services could be 'overwhelmed' by the demand flowing from government initiatives for older people and for heart disease, and the national cancer plan.
'I have no doubts there is a crisis in hospice care, ' says Dr Rob George, NHS hospices and teams representative on the National Hospice Council.
'What is needed is a cash injection into a number of hospices in real trouble, where the shortfall is 20-30 per cent of overall revenue. Without a cash injection we are stuffed.'
If the funding request is accepted by the government, it would mark an historic moment which - for the first time - would see the NHS take on the lion's share of the revenue funding for the fiercely independent voluntary sector hospices.
The National Hospice Council report - still in draft stage - reveals that while the NHS is making ever-increasing demands on voluntary sector providers of palliative services it is, at the same time, reducing its overall contribution to annual hospice revenue costs, which run at around£300m a year.
The NHS currently funds, on average, 31 per cent of independent hospice running costs. But the draft report shows that massive variations in the funding of individual hospices by health authorities and primary care groups have led towidespread inequalities in access to, and quality of, hospice care. It reveals:
The average number of in- patient palliative care beds per million population ranges from 34 in Trent region to 62 in North West and South East - a variation of 82 per cent.
While London has just over 7,000 palliative day-care places, Trent region has over 16,500, a variation of 131 per cent. The English region average number of day-care places is 13,198.
In Trent there are 15 community nurse specialists in palliative care per million population, compared to 30 per million population in South West region - a 95 per cent variation.
The draft report concludes that it is 'unlikely that the differing levels of provision reflect differing levels of need - eg difference in incidence of cancer deaths (and) in levels of socioeconomic deprivation'.
Peter Tebbit, national palliative care adviser for the council, says: 'It's my guess - a hypothesis - but if you mapped palliative care against relative levels of socio-economic deprivation, you would find the most well-developed services are in the most affluent areas.'
The report also says that out-of-hours service are 'deficient almost everywhere, and that the concept of a multi-professional specialist palliative care team - comprising a nurse, doctor and social worker - has yet to become a reality in most parts of the country.'
There is also evidence that hospices are struggling to meet need.While 50 per cent of cancer patients access palliative care, those services are available to only 7 per cent of those with a non-cancer diagnosis.
Although the national service framework for coronary heart disease calls for good palliative care, the council's draft report warns that hospice services may not be able to cope.
'Services may be overwhelmed with referrals. . . Expanding services to non-cancer will put further pressure on already overstretched resources.'
The National Hospice Council has written to health secretary Alan Milburn calling for an immediate 6.3 per cent injection of NHS funding for voluntary sector hospices - equivalent to around£20m.
But the draft plan warns that, in the long term, additional NHS costs would be more than seven times that sum: 'If equity of access is to be achieved for people with palliative care needs and with any diagnosis it is unlikely that the additional costs to the NHS would be less than£150m.'
Mr Tebbit says: 'Individual hospices have been expanding at a fairly rapid rate by about 10 per cent a year on average. NHS income has been expanding at 3 per cent maximum.
You can't go on expanding at 10 per cent a year. If you do that you will double your expenditure every seven years.
You do not have to ask the question whether that is sustainable in the current market for charitable money. At the same time a lot of that expansion has been at the request of NHS commissioners, who say: 'We would like you to do this and that, but we do not have any funds to help you do it.'
General manager of Derian House children's hospice Trevor Briggs says:
'There's no doubt the NHS should be making a much larger contribution. It is reliant on hospices for a lot of critical community-based care, and hospices are relieving pressure on the NHS. It has almost a moral obligation to do so.'
Dr George says that the financial problems are partly due to people realising their 'entitlement' to hospice care - a concept that sits uneasily with a charity-run service, coupled with a squeeze on charitable funds caused not least by the introduction of the National Lottery.
The government has earmarked£23m from the National Lottery new opportunities fund, some of which is for palliative care projects.
But ministers have so far stonewalled on hospice funding, arguing that funding arrangements must be agreed locally though health improvement programmes.
Dr George is unconvinced that NHS commissioners will see it as a priority. He admits that some hospices may have to adapt to the requirements of the NHS if they are to justify the money: 'The cash has to come in, but everybody has to recognise that to attract the money there has to be a level of probity and rigour that the hospice movement has not really approached.'
Taking the strain: 'I feel we are being taken for granted by the NHS' St Christopher's Hospice in Sydenham was the first - and is probably the UK's best known - hospice. But its reputation has failed to prevent it running into financial problems.
Earlier this year the trail-blazing hospice announced that it was£1m in debt, and would be forced to make redundancies and close an eight-bed nursing wing. There were appeals for public donations and NHS cash from its founder Dame Cicely Saunders, and Unison general secretary Rodney Bickerstaffe, whose mother had died at the hospice.
St Christopher's running costs are around£10m a year, of which£2.8m comes from south London health authorities. But managers say demand for its services have tripled in the past six years.
The government bailed it out to the tune of£500,000 in April.
Public donations since the announcement have totalled over£20,000.But hospice managers have warned that it still faces a£500,000 shortfall this year.
In 1993, Sir Richard's Hospice in Worcester provided for 280 patients and had running costs of£418,000, of which the NHS provided 30 per cent. In 2000, its running costs had risen to£1m to cope with 800 referrals, including 500 from the NHS, and 60 per cent of all people in the area with cancer - but the NHS contribution has shrunk to 17 per cent.
'We are grateful for the health authority money, ' says Angela Hughes, fundraising and publicity manager for the hospice.
But she admits the financial situation is precarious. 'What kept us going last year was legacies. Without them we would have had to cut costs, which means jobs and services.'
Sir Richard's hopes to launch a£4m appeal for a bedded unit in the autumn. But he is concerned that it will be unable to meet the unit's£500,000-a-year running costs unless the NHS can step in.
Derian House children's hospice in Chorley, Lancashire, is one of 21 children's hospices in the UK, providing respite and palliative care for ill youngsters and support for their families. It has expenditure of around£950,000 a year, but although it takes referrals from several HA areas, it receives just£20,000 towards its costs from NHS commissioners - roughly 1.5 per cent of its total budget.
What we are looking at is a hospice that is open 365 days a year, with only eight-nine days of statutory funding, ' says general manager Trevor Briggs.
'If each HA which refers to us contracted for just£10,000, that could quite easily reach 10 per cent of our income.'
He is grateful for the NHS funding he receives, but is unhappy that the health service is failing to match with cash its increasing reliance on independent hospices.
He says: 'I feel we are being taken for granted by the NHS.'
Hospices date from the 19th century, but the modern hospice movement came into being in 1967 when Dame Cicely Saunders set up St Christopher's in Sydenham, London.
The movement has largely grown outside the NHS. The voluntary and charitable sector provides the lion's share of hospice and palliative care - including around 75 per cent of inpatient hospice units, amounting to 2,600 beds.
The NHS manages 56 hospice units, providing 6,000 beds. All hospice care is provided free of charge.
An estimated 56,000 admissions are made to hospices every year. Around 29,000 people die in palliative care units annually, including 19 per cent of all cancer deaths.
A further 135,000 people receive palliative home care every year, and around 28,000 new patients receive palliative day care every 12 months.
The hospice movement was largely responsible for developing the science of palliative care - which was formally recognised as a sub-specialty by the medical world only in 1987.
As well as cancer patients , hospices care for people with other life-threatening diseases, including HIV and AIDS, heart failure, kidney disease and motor neurone disease.
Health authorities were first asked by the Department of Health to work together with local palliative care providers in 1987, and the issue has gradually inched up the NHS policy agenda.
In 1996, an NHS Executive letter in the wake of the Calman-Hine report into cancer services stated the aim was to ensure that the benefits of advances in palliative are 'available to all patients wherever they are'.
Two years later, a DoH circular asked HAs and primary care groups to draw up palliative care strategies. Related principles, it said, 'should become integral to the whole of NHS practice and be available to all patients, irrespective of disease, wherever they are'.
Palliative care is a key element of NHS modernisation, such as the cancer initiative, the national service framework on coronary heart disease and the forthcoming national service framework on services for older people.
The NHS plan states that health services, in partnership with partner agencies, need to 'make high-quality palliative and supportive care available to those older people who need it'.
The hospice movement, however, is worried that despite these policy objectives, hospice care will be ignored by purchasers unless ministers make it a clear priority.