My research study involved anonymous interviews with 31 hospice CEOs in all regions of England. [1] In this short article, I look at what they said about development in terms of hospices’ operation as a charity, business, community focused organisation and partner with mainstream services. As one CEO put it to me, hospices will develop more effectively when they are prepared to learn from each sector.
Despite most hospices’ longstanding registration as companies, some CEOs spoke about the need to develop a business approach alongside a charitable one.
For example, one CEO spoke of “moving from not just being a charity … to being a business as well as a charity, we still battle with that on a day-to-day basis”. Another talked about the vital benefits of a “charity sector mentality … wanting to go the extra yard”, rather than simply working to pay shareholders or satisfy governors, coupled with a private sector mentality of “really striving, really reaching for stuff, not accepting the old ways”.
They suggested that going forward, hospices should adopt “a hybrid” approach that builds on the strengths of each sector.
This article is one of a series of four discussing an approach to hospice futures that I call Strategic Tension Recognition or STRV (with ‘V’ signifying visualisation) that can help hospice leaders to recognise and work with the varied perspectives and tensions around them as they look ahead. For a description of the method, see Article 1.
Applying STRV, the semiotic diagram in Figure 1 shows four sectors sitting in tension with each other. In terms of their respective attributes, community sector organisations have intimate knowledge of their communities and are committed to their cohesion and wellbeing.
Charities are usually driven by a cause, and for hospices these days it is around improving people’s experiences at the end of life. Public sector organisations are the experts at working at scale and private sector businesses are known for creating solutions and balancing their books. Of course, we could pick holes in those sweeping generalisations but the gist from CEOs is that hospices can benefit from all of them and hospice development is likely to be more effective where a hybrid rather than a singular approach is adopted.
Figure 1
CEOs recognised that hospices in their early days were paragons of traditional charity sector commitment to a cause and were inspired by deeply held values and belief.
Pioneers showed remarkable courage and self-sacrifice seen, for example, in the extraordinary Sisters of Charity who worked amongst the cramped populations of Dublin that in the 19th century were riddled with highly infectious life-threatening diseases such as cholera, smallpox and typhus. Their spirit of love for the poor, of understanding their hardships, of dedication to their welfare, conceived the idea of a hospice for the dying. All too often this was at the cost of their own lives. [2]
In the second half of the 20th century, champions of local communities came forward to found over 200 hospices in the UK. However, by the millennium it was clear that a more businesslike approach was needed if hospices were to sustain their work, and at the 2010 Help the Hospices Conference, Charles Leadbeater spoke of the need for hospices to develop “intimacy at scale” which, amongst other things, pointed to closer working with the public sector.
In the interviews for my recent study, CEOs expressed concern that some hospices appear to adopt a singular approach. So for example, they felt that many were still limited to a charity sector mentality and that this had exacerbated financial difficulties. Others had swung too far towards a private sector or public sector way of working that was tearing the heart out of their organisations, losing that vital “atmosphere of hospiceness” and destroying the hallmark of what makes hospices so deeply loved by local people and so effective.
CEOs felt that some have lost touch with the needs of their communities and that others were not learning private sector lessons of innovation, flexibility and sustainability. The semiotic drawing (Figure 1) visualises the different sectors and helps us to see how the influences of each one can push and jostle with the others for prominence and sometimes domination in hospices. It can help leaders to visualise where they are and where they want to be in terms of hospice development.
Respondents in the study were clear that no sector should be seen as inferior or superior to another. So, for example, they say that it would be foolish to lose sight of a charity’s inspiration and dedication to a cause and replace it with a colder more efficient approach simply because it looks more corporate, is easier to manage and keeps regulators happy.
There will always be a degree of chaos in community and charity sector endeavours but, provided it does not get out of hand, it can and has been shown to be the engine room for remarkable social achievements that others have missed or ignored.
As one CEO put it, “we are by the community, for the community and of the community … mess with that at your peril”. At the same time, hospices have much to learn from colleagues in other sectors who have also made a tremendous impact on society like, for example, the NHS, universities and research companies during the recent Covid pandemic.
Of course, finding an effective equilibrium in the semiotic (Figure 1) requires a deft touch.
The demands of, for example, the acuity of business and the altruism of charity might appear contradictory but it is not impossible to find a balance if hospices begin by building a meaningful understanding of what they are. So if, for example, as I described in my second article, hospices see themselves as more than an extension of the NHS but rather as a community resource or an instigator of social change as well as being a health and social care provider that needs to be accountable, they will more easily appreciate the value of a hybrid approach to their development.
This brings us back to the title of these four articles, Finding Hospice Futures. I have visualised the main tenor of my discussions in Figure 2.
For hospices to build sound foundations upon which to construct their futures, it would be useful, if not vital, to consider the questions and tensions in this semiotic diagram or STRV as I have called it.
Whether we like it or not, many different perspectives and their consequent tensions coexist in our vibrant landscape. Like the molecular structures of which we are made, it is wise to understand them and foolish not to. If we do not, and jump straight to ‘how’, it is like building the superstructure of a hospice future without investigating the earth beneath its feet.
Figure 2
What emerged from my study, based on the views of 31 CEOs, is that if hospices are to continue to be relevant and effective, they need to reflect on the vibrant energy of their inception, the intricacy of their surroundings, the heterogeneity of their development and their capability of fulfilling their mission.
This will involve working out and understanding the possibilities that are open to them, drawing new comparisons, understanding what they are not and considering what kind of hospice they want and need to be.
For some this may be an ever more intimate relationship with the mainstream and perhaps becoming part of it. For others, it may involve an ambidextrous approach that is agile and open on the one hand and vibrantly connected to the driving force that formed them on the other.
For all hospices, looking forward will involve addressing the ‘why-where-when’ and ‘what-who-how’ conundrum, developing valued relationships with individuals, families, communities, colleagues and partners, and with courage and conviction, continuing to reflect on the long-term significance, meaning and enormity of it all because, “the care of the dying is the care of all of us … in a way it is the dying who are giving us a much better awareness of the gift of life”. [3]
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This is the fourth and final article which Stephen has written for ehospice based on the findings of his doctoral thesis. They appeared 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] 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.
[2] Kerr D. Mother Mary Aikenhead, the Irish Sisters of Charity and Our Lady’s Hospice for the dying. American Journal of Hospice and Palliative Medicine. 1993;10(3):13
[3] Klagsbrun S. Hospice – a developing role. In Saunders C, Summers D, Teller N, eds. Hospice: the living idea. London: Edward Arnold; 1981: 187-194.
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