Can You Die Well in England?

Around 600,000 people die in England each year. The majority of those deaths are expected: cancer, heart failure, respiratory disease, dementia. For most, the question is not whether they will die but how, where, and with what support. Palliative care — the medical, nursing, and psychosocial support for people approaching the end of life — is one of the areas where England has been historically strong by international standards. The UK ranks first in the Economist Intelligence Unit’s Quality of Death Index. But that ranking reflects the availability of palliative care in principle, not in practice for everyone who needs it.

England has approximately 200 hospices, providing inpatient beds, community outreach, and bereavement support. They are, in effect, a parallel healthcare system funded primarily by charity. The NHS contributes just 27% of hospice income — down from 32% a decade ago. The remaining 73% comes from donations, legacies, charity shops, and fundraising events. This model is unique in the developed world: no other comparable country relies on bake sales and charity shops to fund the care of dying people. Hospice UK estimates the sector faces a collective deficit of £77 million per year, with some hospices at genuine risk of closure.

Access to specialist palliative care is unequal in ways that mirror broader NHS inequalities. People with cancer are far more likely to receive specialist palliative care than those dying from heart failure, COPD, or dementia — even though the symptom burden can be comparable. People in deprived areas receive fewer community palliative care visits. Black and Asian patients are significantly less likely to be referred to hospice services, and research consistently shows they are less likely to die in their preferred place. The proportion of people dying in their “usual place of residence” — typically home or a care home, the outcome most people say they want — peaked at 52% during COVID and has since settled back to around 48%.

The NHS Long-Term Plan mentioned palliative care but set no specific targets or funding commitments. The 2024 NICE guideline on end-of-life care recommended that all adults in the last year of life should have access to specialist palliative care if needed, but implementation relies on local commissioning decisions and varies substantially by integrated care board. Some ICBs commission 24/7 community palliative care; others have no out-of-hours provision. The consequence is that people who become acutely unwell at night or on weekends often end up in A&E — the place most people say they least want to die.

Demand for palliative care is growing. Referrals have increased from 188,000 in 2014 to 274,000 in 2024, driven by an ageing population and growing recognition that palliative care improves quality of life. The workforce is not keeping pace: there are approximately 600 palliative medicine consultants in England, and vacancies in specialist nursing are high. The number of people dying each year is projected to increase by 25% by 2040 due to demographic change. Without structural funding reform — moving hospice funding from charity to commissioning — the gap between need and provision will widen.