Written evidence submitted by Marie Curie (AHE0018)

Executive summary

Current public expenditure on adults in the final year of life in England is significant - c. £18 billion in FY2022, over half of which was spent on healthcare.  This health spending is disproportionately distributed towards hospital care rather than well-anticipated, coordinated and holistic care in community settings.  

Only £350 million of the £18 billion total current public expenditure on people in the final year of life in England was spent on hospices in the same year

Hospices are key providers of specialist palliative care and play an important role in working in partnership with the NHS and social care services to meet population need but are just one part of a wider picture of public expenditure that merits deeper scrutiny in its own right.   

90% of the adults who die each year in England need palliative care but an estimated one in four of them are missing out.[1].[2]   

Poor access to 24/7 care in community settings is resulting in significant avoidable use of ambulances, A&E and emergency hospital admissions.   In England, out of a total number of 542,3000 deaths in 2023, 60.3% of all people who died had a least one emergency admission in their last 3 months of life[3]

There has not been a national strategy for improving palliative and end of life care in England since 2008[4], despite successive governments committing to the Ambitions National Framework for Local Action on Palliative and End of Life Care[5] vision since 2015. The Health and Care Act 2022[6] introduced a legal duty for Integrated Care Boards in England to commission palliative care services that meet the needs of their local populations, but this has yet to result in universal access to quality services. 

The Government’s recent commitment to develop a Modern Service Framework (MSF) for Palliative Care and End of Life Care offers a significant opportunity to improve access, quality and sustainability of local services.  3 key actions are need to realise this:  Firstly, the MSF must be closely aligned with the 10 Year Health Plan.  Secondly, it must have clear and ambitious goals, backed by mechanisms to hold commissioners and delivery partners to account where they fail to deliver. Thirdly, it must be clear about how it will be resourced – either through new resource, or by reallocating existing resource.

Without action to reform wider patterns of public expenditure on people in the final year of life, there is a risk that gaps in access and system pressures become worse, even if steps are taken to improve the financial sustainability of England’s adult hospices. 

Marie Curie is the UK’s leading end of life care charity.  Our mission is to close the gap in end of life care.   We are working through partnerships with the NHS and social care providers to meet wider population need for palliative and end of life care in cost-effective ways including hospice care at home services and innovative integrated models of care.   

However, the current funding model for our services is not financially sustainable, and this is preventing the full realisation of our potential to help meet demand for this care. 

Marie Curie is taking active steps to secure our own financial sustainability including increasing fundraised income; controlling and reducing costs; seeking to maximise income from commissioners; and pivoting towards the most cost-effective models of care delivery that meet wider population need.  

Urgent action is also needed by the Government to not just improve the financial sustainability of England’s adult hospices but also shift wider patterns of public expenditure on people in the final year of life.  The Government should: 

• Target a long-term shift in expenditure on the end of life from hospital to community.
• Invest in innovative integrated models of palliative and end of life care which improve access to care for the whole population in cost-effective ways.
• Build a palliative and end of life care workforce that is fit for the future.
• Require Integrated Care Boards to cover the full operational costs of commissioned hospice services, including the costs of the clinical workforce and relevant uplifts, and to move towards multi-year instead of annual commissioning cycles.
• Encourage ICBs to prioritise for investment the models of hospice care that are most cost-effective at meeting population need and achieving the shift from hospital to community for people at the end of life; and
• Make palliative and end of life care a priority for health and social care reform. 

Hospices receive just £350 million of the £18 billion spent annually on people in their final year of life – a fact that should make closing the funding gap for these services affordable within the overall NHS budget. 

However, this inquiry should also consider the broader context of overall public expenditure on people in their final year of life to ensure better value is achieved for the nearly £10 billion spent annually on healthcare for people in the final year of life.  

Variation in accessibility to hospice care

Marie Curie is the UK’s leading end of life care charity.  We bring 75 years of experience and leading research to the care we give at home, in our hospices and over the phone.  And we push for a better end of life for all by campaigning for and sharing research to change the system. During FY 2024/25 we supported 42,271 people through 76,499 episodes of care delivered in homes, hospices and in the community across the UK.  

We are currently developing a new service model which is focused on partnerships with the NHS and social care providers that meet wider population need for palliative and end of life care in cost-effective ways,.   

This service model seeks to actively address a number of key challenges related to access to more traditional hospice services: 

• Inequitable access to hospice services:  A longstanding and important concern is the risk of hospices being a high-quality service for the privileged few due to their reliance on charitable donations, which  results in services being provided disproportionately to places and populations most able to make those donations.
• Improving access to hospice services for groups who are currently least likely to access palliative care.  People with a non-cancer diagnosis, living in a rural or more socioeconomically deprived area, identified as having an ethnic minority background, or aged over 85 years, are currently less likely to receive care through hospice services than other population groups.[7]
• Improving access to hospice care at home for everyone who needs it is a key challenge.  Most people express a preference for home as their place of care at the end of life and there is a clear trend in England towards more deaths taking place in private homes and care homes.[8]
• Innovative integrated models of palliative and end of life care involving partnership working between hospices and the NHS have been shown to be highly effective.   A recent review of the costs- and cost-effectiveness of adult palliative and end of life care[9] found strong evidence that palliative care and end of life care delivered through multi-disciplinary teams, with specialist palliative care integrated alongside specialist and generalist teams, is effective and leads to to improved outcomes for patients and their family caregivers.  These services are associated with reduced avoidable healthcare utilisation and cost savings, including through reduced use of urgent and emergency care and reduced length of inpatient stays.  

The structure of and trends in, funding for hospices and our financial state

Marie Curie is the largest charitable provider of palliative and end of life care services in England and we are currently facing significant financial sustainability challenges: 

Inadequate statutory funding for commissioned services

Marie Curie is not receiving enough statutory funding to cover the costs of the palliative and end of life care services we provide and this is resulting in an over-reliance on charitable fundraising.    On average in 2024/25, the NHS paid for £30.2 million (47%) of the cost of Marie Curie’s Hospice Care at Home services (2024: £31.6 million, 48%) and £18.5 million (34%) of the cost of Marie Curie’s Hospices (2024: £22.1 million, 39%). The remainder of the costs were funded by our generous supporters.

Commissioners routinely offer contracts for commissioned palliative and end of life care services which do not cover the full costs of our clinical and non-clinical staff, or other relevant operational costs.  In recent times, we are seeing some contracts offered at prices which bear no relationship to the true costs of providing complex clinical services, at d prices more akin to those normally paid for domiciliary homecare. 

Contractual arrangements with commissioners are often short term (1-year) contracts with most of the contractual risk carried by our charity.

Challenges in matching NHS pay and conditions

Staff costs make up a significant proportion of our overall costs as a charity.  The agreements reached in recent years between the Government and unions on the NHS pay award and Agenda for Change terms and conditions have placed unplanned and unforeseeable additional pressures on our budget.

Without additional funding, we have faced significant challenges in matching these commitments for our own workforce.  The award of 2% for 2022/3 alongside the lump sum Covid bonus and the consolidated increase in pay of 5% for 2023/4 for Agenda for Change staff in England resulted in us facing an immediate requirement to find £3.6 million additional funding (over previous announcements). 

The subsequent announcement that non-consolidated payments will be made to non-NHS providers such as charitable hospices matching Agenda for Change with their own staff was very welcome, but these payments only cover part of the additional costs we have incurred. 

Over the same period, increases in commissioned revenue has been considerably lower than the increases to pay costs - increases were rarely above 1%.

More recently, the amendment to the Employers NI thresholds from £9,000 to £5,000 and the increase in rate to 15% has created a new £3.0m annual cost for the charity, the cost is not levied on nurses in the NHS, but applies in full to our nurses doing similar work.

Recent government grant funding does not cover the ongoing costs of services

In December 2024, the Government announced £100 million in new grant funding for adult hospices.[10]  Marie Curie received £1.25 million from the first tranche of £25 million released on 26 February 2025 and £3.7 million from the second tranche of £75 million released on 20 July 2025.  

This grant funding was for capital expenditure only.  Although welcome, it does not address our central financial sustainability challenge of covering the ongoing costs of running services.

Challenging fundraising and retail environment

Fundraising is becoming more difficult, with increased costs and competition driving up donor acquisition costs and reducing the net return on investment of current fundraising models.     Fundraising growth is being delivered from a small number of people giving more.  Retail is also becoming less and less viable, due to rising costs. 

Costs of providing services are rising faster than income

Marie Curie is currently running a structural operating deficit, and the deficit has been reappearing each year due to the inflationary cost of delivering services increasing at a higher rate than commissioned income for statutory services.  This places a need for income generated through fundraising and retail to deliver above inflationary growth year on year. 

The current structural position is eroding our charitable reserves and is not financially sustainable. 

Plans to address financial sustainability and accessibility challenges

Marie Curie is taking the following steps to improve the financial sustainability of our palliative and end of life care services: 

Increasing fundraised income:  We are acting to increase our fundraised income, with 2024/5 seeing an increase of 18% to £110.4 million—driven by gifts in wills, strong corporate partnerships and robust regular and direct giving. There is a limit however to how far fundraised income can be scaled in the medium term, as a balance must be found between investment in fundraised and optimised net income. 

Cost-control: During 24/25 Marie Curie has reduced its planned deficit from £25m to £7m through its ongoing focus on reducing the running costs of the organisation. This has been realised through a range of measures, predominantly headcount reduction in our back office support and fundraising teams, and we continue to drive efficiency and reduce costs further. 

Ensuring the long-term sustainability of our commissioned services:  We are rebasing the services we offer in each place to fit within the annual budget envelopes. We are re-negotiating income with commissioners, including embedding a minimum rate card that is set at the most basic level of cost recovery to simply cover the direct cost of nursing.

We have closed our Inpatient Unit in our Liverpool Hospice as the cost of running the facility was no longer affordable and the ICB were not able to provide additional support to cover the increased cost of running such a standalone facility.

We are trying to improve the commercial arrangements with all our commissioning partners; to reflect a fair share of the risks and ensure we are not contracting the organisation to unlimited liabilities..

Investing in new strategic services that are cost-effective and improve access for those who need palliative and end of life care:  Every service we deliver is currently under scrutiny to consider its longer term financial viability.  While the charity is committed to restoring financial balance in 2027, it is also committed to using its reserves to invest in more new service innovation. 

The case for Government investment in palliative and end of life care

There is a strong moral and economic case for the Government to invest in palliative and end of life care services which meet wider population need for this care in cost-effective ways, especially in community settings.   For Marie Curie, the case is especially strong for investment in our:

• Hospice care at home services; and
• Innovative integrated models of palliative and end of life care which are provided in partnership with the NHS and social care. 

Overall cost-effectiveness

In 2021, we commissioned the York Health Economics Consortium to carry out an economic evaluation of our services. The analysis demonstrated the economic consequences of the services we provided, based on data from the financial year 2019/20.[11]

Key findings included: 

• The total return on investment, including benefits to productivity and quality of life, in relation to total running costs estimated for all the analysed Marie Curie services taken together is 372%. 
• Looking at the return on investment in relation to statutory funding only, the total for all services is estimated to be a substantially higher 671%.2 
• Looking at health and social care costs alone – removing the assessments about benefit to quality of life and productivity – the return on investment still stands at a healthy 54%.

Cost effectiveness of hospice care at home services

There is a particularly strong case for the Government to invest more in the services Marie Curie provides in community settings due to these being more cost-effective.    The ROI from statutory funding shows high levels of return for our nursing services provided in community settings, particularly when benefits relating to social care resource use are included. 

When considering the impact on healthcare resource use, the ROI for nursing services is 117%. Including the impact on social care services increases this to 161%. 

Cost-effectiveness of innovative integrated models of hospice care delivered in partnership with the NHS and social care

Marie Curie is developing a new service model which focuses on innovative and integrated models of care delivered in partnership with the NHS and social care providers.   We have provided to the Committee cost-benefit analysis of three current examples of innovative integrated models of care being delivered with partners and each of these shows a clear return on investment and a positive impact on patient care.  

January 2026

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