Hospices in the UK have evolved greatly since their eye-catching proliferation in the 20th century and face a maze of new challenges such as economic sustainability, changing demographics and health needs, social justice, new technologies and assisted dying. In this and the following three articles, I introduce an innovative approach to finding hospice futures that may prove helpful in navigating these challenging waters.
This approach, which I call Strategic Tension Recognition, shortened to STRV (with ‘V’ signifying visualisation), adopts a particular technique of visualisation, known as semiotics, [1] to map commonalities, contrasts and tensions in our contemporary understanding of why hospices are here, what hospices are and how hospices are developing.
This understanding is often taken for granted but, as a former hospice chief executive officer (CEO), I believe that these questions that are such vital building blocks for the future, need to be revisited regularly. Since assisted dying has reached such prominence, I also include an application of this approach to the pertinent question, ‘Who owns death?’.
STRV grew out of research that I completed in 2024 for the University of Glasgow in which I interviewed 31 CEOs of charitable hospices anonymously across all regions of England, exploring fundamental questions about their work and how they saw hospice futures. [2]
Prior to this, during my years as a hospice CEO, the board of trustees had appointed a new chair. In our early discussions I was struck by the fact that he was genuinely surprised and intrigued by the complexity of hospices and the plethora of tensions that pull them in different directions. This intricate network of energy subsequently materialised in the interviews, leaving me with the knotty question of how to disentangle all the threads.
When I had finished interviewing, the combined transcripts were longer than The Lord of the Rings, so there was a mass of material to sift through.
Amongst my emerging thoughts was the recognition that, along with many shared values, there is also a mountain of tensions and contrasting perspectives that leaders face within, amongst and around hospices, locally, regionally and nationally.
Of course, I had been aware of some of these before I began my research but I was still surprised by the scale and variety of outlooks that hospice CEOs described to me.
In considering how to present these issues, I found Ken Gergen, a social psychologist, who uses diagrams to describe how he sees society constructed, enlightening. [3] Gergen visualises groups of people or “intelligibilities” as he calls them adopting different philosophical positions. His semiotic drawings, gleaned from Julien Greimas, a renowned literary scientist, [4] not only depict stances of ‘for and against’ but also the broader societal context around them. Gergen argues that creating multiple semiotic drawings reveals the molecular energy that society and the reality of our lives are made of.
When I was examining my interview transcripts, it felt as though I had thousands of jigsaw pieces lying in a jumbled heap on the floor. In seeking to make sense of them I produced numerous lists of themes, sub-themes, commonalities and contrasts. Whilst that process was helpful, it was not until I began to visualise the tensions amongst them by drawing semiotics in a similar way to Gergen that they sprung into life. Suddenly I saw the energy that I had been grappling ‘with and against’ as a hospice CEO in the molecular structure of the hospice landscape.
To demonstrate how the method works, I now apply STRV to the question, ‘Why are hospices here?’ As we know, hospices have been around since the middle ages inspired by the teaching of Jesus of Nazareth: “I was hungry and you gave me something to eat … I was sick and you looked after me”. [5] Having re-emerged in the seventeenth century, there was a period of extraordinary hospice proliferation in Britain in the second half of the twentieth century. [6] In Figure 1, I summarise responses from CEOs about why they thought so many new hospices were established during that dizzyingly impressive pioneering period.
Figure 1
In the interviews, CEOs described a tension in society between the horrific suffering that people were experiencing and their desperate desire for good or better deaths. Figure 1 displays some of the tensions and energies that hospice pioneers grappled with and inspired them to take the courageous steps that they did.
Of course, there are more reasons behind the 20th century hospice revolution than those summarised here but, as Gergen suggests, this reminds us that multiple semiotics are needed to paint a more complete landscape.
Moving to the question of why hospices are here today. I’ve summarised responses from CEOs in Figure 2. Here one sees different language emerging, with the polar tension being between Society is still not doing death very well and the aspiration of people to Celebrate life and dignify death.
Figure 2
The arrows show that the commonalities, contrasts, energy and tensions visualised in semiotics work in all directions. So, for example, just as there is a tension to be worked with in how we blend institutional power with personal control there is also a tension between satisfying standards and guidelines and meeting human need.
As I looked at the boxes in the diagrams, as well as thinking about what respondents told me, I found myself thinking, ‘Where am I in all this?’
As a CEO, did I find the right balance between routinisation and management and commitment and belief?
Did I encourage creativity, vision and inspiration in those who used their imagination to do things differently or was I too concerned with efficiency and accountability?
Did I really understand the paradox of hospices being challenged to provide “intimacy at scale” and how to address it? [7]
Did I grasp the profound significance of Cicely Saunders’, “truth of the mind in skill and understanding with truth of the heart in vulnerable friendship”? [8]
Semiotics is a broad and complex field with Aristotelian roots [9] but creating them in the way that I have described is not difficult. In the polar meridian, the north and south boxes show the broadest differences or opposites in the subject of the semiotic. This helps those drawing the diagram to contextualise and understand the semiotic as a whole. The boxes between the poles (and these can vary in number) show contrasts within the subject field under consideration. To begin, colleagues might draw a known tension in two side boxes that subsequently helps them to identify the polar contrasts. Alternatively, they might begin with the overarching difference that enables them to identify constituent tensions. When one semiotic has been drawn, new insight will lead to multiple semiotics and the emergence of a fuller picture.
I find semiotic-based STRV fascinating because it reveals the dynamics of what was or is happening in a situation or given problem in a vibrant and accessible way. As with workplace action plans, the ones that mean the most are not written by bosses but by teams working together. Likewise, semiotics spring to life when individuals or groups create their own helping them to explore shared values and contrasting perspectives more openly and easily.
In these articles, I offer a snap shot to help leaders step back and consider some of the most fundamental questions that need to be answered in order to build effective and sustainable hospice futures. I have already described STRV in presentations and workshops with hospice leaders and I am delighted that they found it exciting and refreshing because this approach draws out and embraces hidden perspectives. As a consequence, it offers new insight into the dynamic landscape in which hospices live, breathe and operate.
In this time of economic struggle and global uncertainty, building sound foundations for the future in our shared endeavours with families, communities, colleagues and partners has perhaps never been more important.
In my next article, I explore the question, ‘What are hospices?’
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This is the first of four articles which Stephen has written for ehospice based on the findings of his doctoral thesis. They will appear weekly as follows:
Finding Hospice Futures: Exploring why hospices are here, what hospices are and how they are developing
1 Finding Hospice Futures by exploring and visualising why hospices are here
2 Finding Hospice Futures by exploring and visualising what hospices are
3 Finding Hospice Futures by exploring and visualising who owns death
4 Finding Hospice Futures by exploring and visualising how hospices are developing
Stephen Greenhalgh is a former hospice chief executive and board member of Hospice UK. He is currently a Trustee of Wigan & Leigh Hospice in Greater Manchester. These articles are based on his doctoral thesis with the University of Glasgow, completed in 2024. Its title is: Exploring and visualising the purpose, concepts and development of hospices in England from the perspective of hospice chief executives.
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[1] Greimas AJ. On Meaning: Selected writings in semiotic theory. Minneapolis: University of Minnesota Press; 1987. [2] Greenhalgh S. Exploring and visualising the purpose, concepts and development of hospices in England from the perspectives of hospice chief executives [PhD]. University of Glasgow, UK; 2024. [3] Gergen KJ. Realities and Relationships Soundings in Social Construction. Cambridge, MA: Harvard University Press; 1997. [4] Greimas AJ. On Meaning: Selected writings in semiotic theory. Minneapolis: University of Minnesota Press; 1987. [5] Matthew 25: 35-40. In: Holy Bible New International Version. Hodder and Stoughton Limited; 1986. Saunders C, Foreword, Oxford Textbook of Palliative Medicine 3rd edn. Oxford University Press. 2004. [6] Clark D. Cicely Saunders A Life and Legacy. Oxford: Oxford University Press; 2018. [7] Leadbeater C. Dying for Change. Presented at: Help the Hospices Annual Conference 2010. [8] Saunders C, The Founding Philosophy. In Saunders C, Summers D, Teller N, eds. Hospice: the living idea. London. Edward Arnold; 1981:4. [9] Tabler J, Hebert L, An Introduction to Applied Semiotics: Tools for Text and Image Analysis. London: Routledge; 2019.
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