آسایشگاه های داوطلبانه در انگلستان :آیا این یک مدل کسب و کار مناسبی است ؟

This article is concerned with how the UK Government's End of Life Care Strategy seeks to draw upon the capacity and additional choice provided by voluntary charitable hospices in England. Constructing a hospice financial business model we consider the extent to which the policy intersection outlined in the Governments End of Life Care Strategy between Primary Care Trust (PCT) commissioning and the contribution of voluntary hospices is now robust or fragile going forward. Analysis in this paper reveals how charitable income streams donated to voluntary hospices are significant relative to government funding but that this income is uncertain and volatile. Hospices trustees thus maintain balance sheet reserves and invest in capital markets to secure additional financial leverage. In this paper we argue that this serves to recycle and amplify financial uncertainty at a time when the demand for palliative care will increase. The UK population is ageing and hospices are under pressure to provide increased scope for end of life care. Government policy must address the contradictory forces that operate within the hospice business model to secure the capacity to deliver palliative care and patient choice going forward.

This article is concerned with the provision of palliative care services in England by voluntary charitable hospices. The literature on voluntary hospices is fragmented and scattered within academic and practitioner discourses but collectively this reveals the challenges facing this sector. Specifically, how the provision of hospice palliative care has changed over time in response to patient needs and regulatory requirements especially when 80% of specialist in patient palliative care capacity in England is located in voluntary hospices (McDermott, 2005). Hospices have responded to the increased demand for their services (in stay and hospice at home visits, and broader holistic care) by developing and consolidating a range of income to maintain service capacity and meet regulatory demands. However, hospice income is uncertain and often volatile as it arises from charity shops, legacies, lotteries, fundraising and financial market holding gains. Hospices’ trustees, following appropriate governance within this sector, operate with significant balance sheet reserves not only as a hedge against uncertain income but also leveraging additional financial return on invested assets. Reserves are subject to “mark to market” accounting in compliance with Accounting and Reporting by Charities (Statement of Recommended Practice, SORP1). The global credit crunch has negatively affected hospices in terms of sustaining donations, predicting the value of legacies and extracting “mark to market” holding gains that, in recent years, all served to inflate reserves held for revenue contingency and longer term capital projects. Voluntary charitable hospices make a significant contribution to end of life care and increase choice for patients either as an in stay patient or through the hospice at home network and this is recognised in the Government's End of Life care Strategy. (Department of Health, 2008 and Department of Health, 2009). In July 2008, following consultation over two years, the Department of Health published its End of Life Care Strategy (the Strategy) which aims to improve the provision of care for all adults approaching the end of their life, including support for their families and carers. The Strategy centres on: Developing specialist palliative care outreach services by encouraging PCTs and hospices to work together to provide appropriate support to all adults in the community, regardless of their condition. (National Audit Office, 2008a, p. 5) This paper considers whether the policy intersection between Primary Care Trust (PCT) commissioning and contribution of voluntary hospices as outlined in the Government's ‘End of Life Care Strategy’ is founded upon a robust or fragile business model.

The Government's end of life care strategy draws upon the capacity and additional choice provided by charitable voluntary hospices in England. The purpose of this article is to consider the extent to which the policy intersection outlined in the Governments End of Life Care Strategy (2008) between Primary Care Trust (PCT) commissioning and the contribution of voluntary hospices is robust or fragile going forward. In order to investigate this issue we have extracted financial data from the top 25 hospices that report their financials following SORP. Our analysis reveals that although hospice income has grown by an average rate of 7% in recent years this conceals variability and volatility. Hospices report their income by type: donations; legacies; trading; investment; and government/PCT; and a number of these components are volatile, for example legacies and donations. Hospice managers and trustees are motivated to increase their investment in palliative care services but this also requires additional expenditure in activities that drive funding and trading activity. Frequently, expenses run ahead of uncertain and volatile income streams and good governance requires trustees to maintain adequate balance sheet reserves. The general policy is to split hospice reserves into cash held in deposits and funds managed by investment banks where portfolios include equity shares and property. In the ‘good years’ hospices have extracted holding gains to boost income or finance capital projects but the current financial crisis exposes hospices to capital market risk as investments are marked to market and holding losses incurred. The state-voluntary sector policy intersection outlined in the Government’ end of life care strategy depends on the stability of the hospice business model going forward. Our argument is that the hospice business model is fragile due to both income volatility and the necessity to widen the range of end of life services in order to anticipate population dynamics and policy initiatives. If the Government is to secure a strong partnership with voluntary hospices it will need to consider how it can contribute to stabilising the underlying financial business model. This paper argues that unless action is taken to strengthen the hospice business model financially, the capacity to deliver patient choice and hospice palliative care going forward is at risk.