On August 1st, 2021, the formal merger of two independent Birmingham Hospices, St Mary’s, and John Taylor, came into being. ehospice spoke with their CEO Simon Fuller.
eh: Thank you, Simon, for agreeing to this conversation. Perhaps you could begin by telling us something about yourself and your current role.
Thank you, David, for this opportunity to share some of the lessons we have learned during this merger. I am a nurse by background, and I worked in adult cancer & palliative care services before moving into NHS management. I left the NHS 15 years ago when I became Director of Services at the Teenage Cancer Trust where I remained for 11 years.
I have always been interested in Hospice Care, both professionally and personally. I joined Donna Louise Children’s Hospice in Stoke as CEO and while there I led a process leading up to the amalgamation with the nearby Dougie Mac (Douglas McMillan Hospice.) The aim was to protect services for children by cutting governance and management costs and I believe we succeeded in doing just that. I was clear from the outset that I would step down at the appropriate time in this process.
In January 2021 I became CEO of both Birmingham St Mary’s and John Taylor hospices. The decision to merge had already been made though the pandemic slowed down the process. I was appointed to drive this through, and the merger was completed on the first of August.
Both Birmingham St Mary’s & John Taylor were independent hospices though historically John Taylor began in the NHS and then became a CIC before becoming an independent charitable hospice.
The agreement to merge had been made in principle before I joined. The two boards still worked separately but Harry Turner was the chair of both – a significant step. Then they appointed a joint CEO – Penny Venebles, previously CEO of John Taylor who was close to retirement and I joined when she stepped down. Due diligence took place over a 9-month period which then enabled the two boards to formally agree to merge on 1st August.
We are now formally the ‘Hospice Charity Partnership’ but this is only the legally registered name. We still operate under the two brands of Birmingham St Mary’s and John Taylor. This was key to taking the community with us. They have a strong affinity with the historic names and identities. It is possible that the public still think of them as two different hospices – which is fine – and it is key for fundraising!
eh: Merging services is a huge undertaking. What drove the decision? Was it a ‘no-brainer’?
There were several reasons behind our thinking as follows:
- Hospices have been shoring up services through fund raising for many years and the fundraising environment has changed significantly over the last 10 years. Particularly so at a local level as national charities have become very adept at localising their message and their brands. It is more competitive than ever and, consequently, we are having to spend more on fundraising and the return on investment isn’t as good as it used to be.
- At the same time as finances have tightened, governance & management costs have increased. We are highly regulated and this brings with it extra costs.
- As one organisation we believed we would have a stronger voice across the health system, it allows us to be more agile in designing services with our NHS partners and allows us to be more responsive to the needs of the communities we serve.
So, considering the challenging financial environment caused by growing operational and fundraising costs it becomes a moral question to ask what the right thing is to do. Do we cut services or explore merging so as to make savings which then allow you to build a stronger foundation to grow services rather than reduce them?
So far we have achieved total savings of £830k p.a. The savings are largely from management costs and there are also systems/infrastructure savings to be released. We are also able to be more flexible with how we use our workforce. Not needing two Executive teams, two heads of fundraising, finance, HR etc made significant savings on salaries.
Today the combined turnover is about £15M. Having reduced our deficit, we are in a stronger financial position, and we have been able to underwrite an urgently needed new service model. We have £5M in reserve and about 56% of our clinical costs are covered by the NHS.
This level of NHS support is critical as we have a very challenging demographic where fundraising is difficult. We cover Greater Birmingham with a population of 1.3 million people. The more affluent areas are covered by St Giles Hospice in the north and a Marie Curie hospice to the south. We are in the middle trying to reach a very challenged health community – diverse, huge health inequalities – with complex health & social needs. Our Clinical Commissioning Group is the biggest in the country and very onboard with what we are trying to achieve but have significant competing priorities.
eh: Can you say more about your new service model and relationships with community services and commissioners?
During the pandemic we quickly developed, with partners, a twenty-four hour, seven day, out of hour’s referral service enabling a rapid response for palliative and end of life care. This worked well and was flagged as best practice. Currently there is a pause in the service for a mix of funding and staffing reasons.
The challenge is that commissioners can only commit to 12-months funding so there is a risk to us in investing in this as their support might not continue year on year. The approach has shown to reduce hospital admissions, a key target for all of us, but commissioners are hamstrung by the financial position they are in. We have reduced our deficit, demonstrated the need for and value of a new service, yet struggled to get long term funding commitment for it.
This is the nature of funding for anyone not a part of the NHS. I have worked in commissioning, and it is a tough job. They have finite resources and are always having to drive for efficiencies. No one can take risks. They are told to make savings yet to do this you have to invest in something new, to create a parallel service which you can eventually move across to. This said, I remain hopeful that we may get a longer-term commitment.
The business case was for £1M. The commissioners agreed to £500k as we knew we could cover the remainder by working differently and integrating the new service with the existing service, we are able to hold up our end of the arrangement, hopefully commissioners will also find a solution to provide ongoing funding.
Regarding community services – we have to work collaboratively if we are going to meet the needs of our communities going forward. Demand is going to be huge. We need to be clear of our role and how we work with others. We cannot deliver without District Nurses and other community services. If we don’t work closely with them, we are not doing the right thing for our patients.
There needs to be a lot of bravery and honesty around what the future is for hospice care and I feel there needs to be a greater emphasis on specialist community services. There is still a lot of focus on hospice as a building/place – we have 16 beds open at each of our two sites – and yet we must ask how best to provide care wherever it is required, which can only be done in partnership with District Nurse’s and other services.
Our biggest challenge continues to be how to reach the people we know are out there who are desperate for end-of-life care. We don’t have the resources to get to everyone. We can potter along, doing what we do, but we owe it to our communities not to do that. We must keep the discussion and debate going while meeting our financial challenges. Sustainable income is required to build the services we want to. We need to build a collective of people who share the vision of providing timely and responsive specialist palliative care and a ‘quality death’ for all. We need to have the same commitment to this as we do for bringing a safe passage into the world for children through Maternity services.
eh: How important is it to have retained your charitable status?
I believe it is very important to maintain our autonomy so that we can speak up on behalf of the people we serve.
We are going to be doing much more lobbying at a local level in order to raise awareness and to hold people to account. If you are not independent it reduces your ability to have that strong voice on behalf of your community. We are a bit timid. I learned from the Teenage Cancer Trust that we don’t need to be afraid to fight on behalf of the people we represent. And if we don’t who will?
I am not there to be pushing commissioners under the bus when things get difficult but we have a moral obligation to stand up for the community and say that they need better. We should be prepared to take a stance.
Recently St Gile’s Hospice had to make the difficult decision to withdraw from its arrangement to run the Adult Hospice in Walsall; they weren’t getting sufficient income for the service they were providing and found fundraising hard in that area. St Giles are an incredible organisation, very well led, but forced to make a tough decision, I know not taken lightly. The Walsall Hospice is now run by the NHS Trust.
It was only a 18months ago that Acorns Children’s Hospice in the Black Country was on the verge of having to close its Walsall Hospice before commissioners stepped in and the local community raised funds to help save it. Again, a brilliantly run organisation forced into a corner, this is the reality of the times we find ourselves in.
I think that there is a tipping point, perhaps when the NHS funds say 70-80% of the costs of running a hospice. Perhaps, then it does make more financial sense to be absorbed into the NHS. The risk is that this will dilute the role of specialist palliative care, stop organisations from freely advocating for those we serve, as well as the ability to innovate and take risks in exploring new models of care.
Fundraising would undoubtedly fall away taking this approach. The bottom line is that the NHS needs to fully pay for what it commissions, Hospices can then fundraise for the additional services without having to shore up the shortfall in NHS funding. As the hospice movement we carry this because of our commitment to truly holistic services.
eh: What is your advice to other hospice services exploring mergers?
Most importantly to be honest with yourselves. Don’t let personal agendas get in the way. What is the right thing for your community and your patients? Where is the moral compass pointing? Be brave and willing to challenge those who are not comfortable with change.
If you want to demonstrate your effectiveness and efficiency to your community yet have relatively high management costs – is that morally right? If there are people you can share those costs with, and it doesn’t have to be a full merger, isn’t there an obligation to explore? There are various models which can be considered.
There are certainly many challenges – in particular the pain of losing some staff. It is hard and not pleasant but sometimes you have to go through this for the greater good.
There are two models here. Either you lock yourself in a darkened room and then drop the news on people. The so-called immersion approach with short term pain yet greater shock. Or you engage in the process, transparently, which may lose some people in the process and can increase uncertainty. I prefer this, to explain and engage and I believe it is the ethical option.
One piece of advice I wish I had been given is that you can’t, as a CEO, do the people aspect of the merger and the legal process/due diligence. The legal will draw you away from the people aspect. Bring someone in to do the back of house work.
eh: Thank you Simon for your time and willingness to share so openly.
Thank you for your interest. If anyone wishes to contact me then they are very welcome. We are always happy to share our experience.
I can be contacted via email: firstname.lastname@example.org
We are at the beginning of a journey!
eh: We look forward to receiving further contributions from you keeping us abreast of developments. All good wishes to you and your team.