Palliative Care Is Not an Add-On

Last week I listened to Toby Porter, CEO of Hospice UK being interview by the BBC. That conversation prompted this piece. Toby is someone I had the great pleasure of working with some years ago when he was CEO, HelpAge International. I was shocked by what I heard.

Hospices across England ended the last financial year with a collective deficit of more than £70 million, more than double the previous year. Almost six in ten have either made cuts or are considering them. The number of hospice beds out of use rose from around 300 in 2024 to 380 in 2025. 160 were permanently closed. Specialist community hospice visits fell by more than 150,000 in a year.

The figures are British, but the pressures are not. They took me back to my father, William Harry.

Dad had been in palliative care for four weeks when Mum and I were told he would likely be transferred to a long-term care bed. I remember asking the registrar whether this was because he was not dying quickly enough.

II remember the disbelief. His dying did not fit neatly enough within the time and capacity available.

Palliative care is essential health care, yet too often it is treated as an add-on rather than part of the core system. Across OECD countries, the number of people requiring end-of-life care is projected to be 10 million by 2050, driven by population ageing and chronic disease.

That growing need has consequences for capacity. Palliative care requires skilled clinicians, staffed beds, community services and coordination across settings. None of that can be created at the moment a person needs it. It has to be planned and funded in advance.

I think there is, but we need to be precise.

I am not suggesting that hospice beds are closing because policymakers consciously value older people less. Palliative care is needed across the life course.

Structural ageism can be quieter than an explicit decision. It can be visible in what we repeatedly fail to plan for, finance adequately or consider urgent.

A 2024 systematic review of 53 studies found that older people with cancer experienced poorer symptom control and poorer quality of palliative care. Evidence on access was mixed, although 12 studies found older people less likely to receive basic or specialist palliative-care services.

The harder question is why we have become so accustomed to underinvestment in palliative care, when so much of the need falls later in life, and whether ageism is part of the answer.

We would be alarmed if cancer services routinely closed beds because core funding was insufficient. Yet when hospice beds close, community visits disappear or an older person has to move because their dying is taking longer than anticipated, the discussion can become strangely administrative: beds, turnover, eligibility and length of stay.

Behind those terms is a person.

Before Dad was admitted to the hospice, the social worker suggested discharging him home with support from a palliative care nurse. No one had assessed whether home was a safe or realistic option.

My mother was 91, barely five foot two, the house was not accessible, and Dad could no longer transfer from bed to chair. The hospital needed the acute-care bed. So we were relieved to hear, “a bed has just come up,” and William was transferred within a couple of hours.

Many people want to die at home, and that preference should be respected. But choice is only meaningful when the care needed to make it possible is funded. And it is safe for all. Otherwise, what looks like a person’s choice can become a response to pressure elsewhere in the system.

Home is a place, not a care system. Dying at home may require skilled nursing, equipment, symptom management, respite, overnight support and someone able to respond when their condition changes. Without them, care shifts onto spouses, daughters, sons and friends.

The OECD has shown that in a third of member countries, public protection covers only part of end-of-life costs, increasing reliance on families and out-of-pocket spending. Yet between 32% and 67% of end-of-life expenditure is still directed to hospitals.

Which brings me back to Toby Porter and the work of Hospice UK, and to others facing similar pressures.

There is something fundamentally wrong when essential hospice care depends on cake stalls, raffles, charity shops and the generosity of communities to keep core services running.

Fundraising can enrich hospice care. It should not be what keeps beds open and nurses employed.

Core palliative care should be funded as essential health care, with enough staffed inpatient capacity and properly funded home and community care to make genuine choice possible.

My father was dying on his own timetable.

A humane health system must be able to stay with people for however long dying takes, wherever they are cared for.