Who should pay for hospice care? The gap between NHS rhetoric and charitable reality

The debate in brief

Around 170 charitable hospices operate across England, providing end-of-life care to roughly 300,000 people each year. The NHS funds around one third of adult hospice costs on average. The remaining two-thirds comes from charitable income: shops, legacies, fundraising events, and public donations. This means that access to a good death in England depends substantially on where you live, how successful your local hospice is at fundraising, and whether a charitable organisation exists nearby at all. Palliative care is a core component of healthcare by any reasonable definition, yet it is funded as though it were an optional extra delivered by the goodwill of the voluntary sector.

Quick takeaways

The arguments

The case that hospice care should be fully state-funded

Palliative care is healthcare. It is not a luxury, a nice-to-have, or a discretionary service that charities provide out of compassion. The World Health Organization classifies it as an essential component of universal health coverage. The NHS Constitution promises comprehensive care, free at the point of use, based on clinical need. End-of-life care falls squarely within this promise. That approximately 70% of the cost of delivering it in England is met by charity rather than by the state represents a fundamental failure to honour that commitment.

The consequences of this funding model are tangible. Hospice UK's annual funding survey has consistently documented wide variation in statutory funding levels across the country, with some integrated care boards providing significantly more per head of population than others. Marie Curie's research has shown that people in more deprived areas are less likely to die in their preferred place and less likely to access specialist palliative care. The postcode lottery is not a metaphor. It is a measurable disparity in end-of-life outcomes driven by the absence of consistent national funding.

The Health and Care Act 2022 placed a new duty on integrated care boards to commission palliative care services, for the first time giving it an explicit statutory footing. This was widely welcomed by the sector. But a legal duty without adequate funding attached to it changes very little in practice. Integrated care boards inherited the same constrained budgets and the same reliance on charitable providers absorbing most of the cost.

The case for the current mixed model

Defenders of the current arrangement — to the extent that anyone explicitly defends it — point to several features. Charitable hospices have historically been able to innovate in ways that NHS services have not: hospice at home programmes, bereavement support, complementary therapies, family-centred care, and the holistic model of attending to physical, emotional, and spiritual needs were all pioneered by the voluntary sector rather than the statutory system. Independence from the NHS gives hospices clinical flexibility, responsiveness, and a culture of care that many families value precisely because it is distinct from the hospital experience.

There is also a practical argument. Fully integrating hospice care into NHS commissioning would mean bringing approximately 200 independent charitable organisations under NHS governance structures, contracting frameworks, and procurement processes. The track record of NHS commissioning in other service areas — where competitive tendering has driven down quality, squeezed providers, and prioritised cost over outcomes — does not inspire confidence that state-funded hospice care would necessarily be better hospice care. The sector's concern is not that government funding is unwelcome, but that the terms on which it might come could compromise the very qualities that make hospice care effective.

The structural dependency problem

The most uncomfortable aspect of the debate is neither the principled case for state funding nor the pragmatic case for independence. It is the structural dependency that has developed over decades. Hospices fill a gap that the state has never properly funded. Because they fill it, the political pressure to fund it properly never reaches a critical point. The better hospices are at fundraising, the less urgency government feels to commission the service adequately. The sector's success in maintaining services through charitable income has, paradoxically, enabled the chronic underfunding to persist.

This dynamic is not unique to hospice care — it runs through the relationship between charities and the state across multiple service areas — but it is particularly stark here because of the nature of the service. End-of-life care is not an area where patchy provision is an inconvenience. People who do not receive adequate palliative care die in more pain, with less dignity, and with greater distress to their families. The cost of the funding gap is measured in suffering.

The evidence

Hospice UK, the national membership body, provides the most comprehensive data on the sector's finances. Its regular funding analyses have documented that the average adult hospice receives around one third of its income from NHS and public sources, with the remainder coming from charitable fundraising, retail, legacies, and investment income. Total charitable expenditure on hospice and palliative care across the UK exceeds 1.5 billion pounds annually. Hospice UK has estimated that the sector would need at least 350 million pounds in additional statutory funding per year to close the gap between what the NHS pays and what hospice care actually costs.

Marie Curie's "Dying in Poverty" research (2023) found that one in four people die in poverty in the UK, and that these individuals are significantly less likely to access specialist palliative care. Its "Better End of Life" report documented persistent inequalities in access to palliative care by geography, ethnicity, diagnosis, and deprivation. The data consistently shows that the people least able to access charitable provision are the same people whose local NHS commissioning is weakest.

The Care Quality Commission's "State of Care" reports have repeatedly flagged variation in end-of-life care quality and access as a concern. CQC inspections of hospice services generally rate them highly — the vast majority are rated good or outstanding — but this masks the underlying fragility of organisations running on charitable income with no guaranteed funding base.

NHS England's Palliative and End of Life Care Strategic Clinical Networks produced data showing that around 90,000 people per year who would benefit from palliative care do not receive it, a figure cited by both Hospice UK and Marie Curie in their advocacy. The gap is not only financial but structural: workforce shortages in palliative medicine, insufficient community nursing capacity, and inadequate out-of-hours provision all contribute.

Current context

The period since late 2024 has been the most acute funding crisis in the charitable hospice sector's history. The employer National Insurance Contributions increase announced in the October 2024 Autumn Budget, effective from April 2025, added an estimated 30 million pounds in annual costs across the hospice sector. Unlike the NHS and public sector, hospices received no automatic exemption or uplift to cover this increase.

The resulting pressure was severe enough to prompt direct sector intervention. Hospice UK launched an emergency campaign warning that hospices faced service cuts, bed closures, and potential insolvency. In December 2024, the government announced a 100 million pound capital funding package for hospices across England — the largest single injection of public money into the sector. The allocation was widely described as a short-term rescue rather than a structural solution, and hospice leaders cautioned that it addressed immediate pressures without resolving the underlying funding gap.

Integrated care boards are now under the statutory duty introduced by the Health and Care Act 2022 to commission palliative care, but the NHS itself faces severe financial constraints. The 2025-26 planning round showed that most ICBs are in deficit or managing significant savings requirements. In this context, the prospect of a meaningful uplift in NHS funding for hospice care remains distant.

Last updated: April 2026

What this means for charities

Hospice funding is the sharpest example of a dynamic that affects charities across the health and social care landscape: the voluntary sector subsidising what is functionally a public service, with no mechanism to recover the full cost of delivery and no political pathway to a sustainable funding settlement.

For hospice charities specifically, the operational implications are constant. Fundraising teams must generate millions each year simply to keep services running. Reserves are drawn down to cover operating deficits. Capital investment in buildings and equipment competes with the imperative to maintain frontline care. Workforce recruitment and retention are complicated by the inability to offer pay and conditions comparable to NHS equivalents, despite the work being clinically equivalent.

For the wider sector, the hospice funding debate illustrates the risk of being too good at filling gaps. Charities that succeed in maintaining services despite inadequate statutory funding do not create political pressure for reform. They absorb it. The lesson — uncomfortable as it is — is that the decision to keep delivering in the face of underfunding is also a decision to sustain the conditions that produce the underfunding.

Common questions

Why doesn't the NHS fund hospices fully?

The NHS has never fully funded hospice care because the modern hospice movement developed outside the NHS. The first modern hospice, St Christopher's in London, was established by Dame Cicely Saunders in 1967 as a charitable foundation. The model spread through charitable initiative rather than NHS planning, and the funding arrangements that grew up around it reflected this origin. Successive governments have treated charitable hospice provision as a complement to NHS services rather than a core commissioning obligation. The result is a hybrid model where the state contributes a minority share and charitable income covers the rest.

What did the Health and Care Act 2022 change?

The Act placed a duty on integrated care boards to commission palliative care services for the first time, giving end-of-life care an explicit statutory footing in NHS commissioning. Previously, palliative care commissioning was discretionary, meaning ICBs (and their predecessor clinical commissioning groups) could choose how much, if anything, to spend on it. The duty was welcomed by Hospice UK, Marie Curie, and other sector bodies, but they have consistently noted that a duty to commission without ring-fenced funding does not guarantee adequate provision.

How does the postcode lottery work in practice?

Hospice UK's data shows that NHS funding per head of population for palliative care varies by a factor of several times between the best- and worst-funded areas. A person living in an area with a well-funded integrated care board and a strong local hospice may have access to inpatient beds, hospice at home, day services, bereavement support, and 24-hour advice lines. A person living in an area with weak commissioning and no local hospice may have access to none of these. Diagnosis also matters: most hospice provision has historically been oriented toward cancer patients, with people dying from heart failure, respiratory disease, dementia, and other conditions receiving significantly less specialist palliative care.

What was the 2025 emergency funding package?

In December 2024, the government announced 100 million pounds in capital funding for hospices in England, distributed through Hospice UK. The package was a direct response to the financial pressure created by the employer NIC increase and broader cost inflation. Hospice UK described it as a necessary but insufficient measure — necessary because it prevented immediate service closures, insufficient because it was a one-off allocation that did not address the structural funding gap. The sector has called for a long-term, recurrent funding settlement rather than emergency interventions.

Are children's hospices funded differently?

Children's hospices face an even more acute version of the funding gap. NHS England has provided some ring-fenced funding through the Children's Hospice Grant, but charitable income still accounts for the majority of children's hospice costs. Together for Short Lives, the national charity for children's palliative care, has reported that children's hospices receive around 15-16% of their income from statutory sources. The smaller patient population and higher per-patient cost of children's palliative care make fundraising particularly challenging.

Could hospices survive without charitable income?

Not under the current funding model. If charitable income were withdrawn tomorrow, the vast majority of hospices would close within months. The NHS does not have the capacity, infrastructure, or workforce to absorb the patients and families currently served by charitable hospices. This dependency runs both ways: the NHS depends on hospice charities continuing to fundraise successfully, and hospices depend on the NHS contribution, however inadequate, to remain operational. The arrangement is a mutual dependency built on a foundation that neither side controls.

Key sources and further reading

• Hospice UK Funding Data and Analysis — Hospice UK, published periodically. The primary source for data on the statutory and charitable funding mix for hospices in England, including variation by integrated care board area.

• "Dying in Poverty" — Marie Curie, 2023. Research documenting that one in four people in the UK die in poverty, with analysis of how deprivation affects access to palliative care.

• "Better End of Life" Report — Marie Curie, 2024. Comprehensive analysis of inequalities in end-of-life care access by geography, ethnicity, diagnosis, and socioeconomic status.

• Health and Care Act 2022, Section 21 — UK Parliament. The legislative provision placing a duty on integrated care boards to commission palliative care services, giving end-of-life care its first explicit statutory footing in NHS commissioning.

• "State of Care" Annual Reports — Care Quality Commission (CQC). Regular assessments of the quality and accessibility of health and social care services in England, including end-of-life care provision.

• The Road Ahead 2025 — NCVO, 2025. Annual outlook for the voluntary sector, including analysis of the employer NIC impact on charities delivering health services.

• Together for Short Lives Funding Reports — Together for Short Lives. Data on the funding gap for children's palliative care, including the proportion of children's hospice costs met by statutory sources.

• Civil Society Almanac 2024 — NCVO, November 2024. Sector-wide financial data including charitable expenditure in health and social care subsectors.

• NHS England Palliative and End of Life Care Framework — NHS England. The national framework for palliative care commissioning, setting out expectations for integrated care boards.