Background Inequality in hospice care is a considerable concern in the modern healthcare system in the UK and beyond, with the underrepresentation of people with diverse backgrounds and a lower socio-economic class among hospice patients (Tobin, Rogers, Winterburn, et al. BMJ Support Palliat Care. 2022;12(2):142–151). Psychological support is a crucial domain of holistic care (Cadet, Davis, Elks, et al. Healthcare 2016;4(4):88). In hospice care, psychological support is facilitated by multiple healthcare professionals within a stepped care system when patients with more complex psychological needs are referred to a higher level of psychological support (NICE. Improving supportive and palliative care for adults with cancer. NICE guideline (CSG4); 2004). Due to an unclear referral pathway (McInnerney, Candy, Stone, et al. BMC Palliat Care. 2021;20(1):31), inequality may continue within the hospice care system, with less privileged individuals being less likely to get a referral to psychological specialists (i.e. psychologists, psychiatrists, counsellors and psychotherapists).

Aims This study investigates why healthcare professionals working in hospice care decide to refer patients and their families for specialist psychological support. Additionally, it aims to provide recommendations to improve communication between psychological specialists and hospice staff involved in referrals.

Methods Nine focus groups and four interviews were conducted with healthcare professionals working in eight UK hospices. Reflexive thematic analysis (Braun, Clarke. Thematic analysis: a practical guide. SAGE; 2022) was used to analyse the data.

Results Themes are currently being developed and elaborated. Candidate themes include ‘sixth sense acquired through experience’, ‘beyond my limits’, ‘mental health conditions preceding the terminal diagnosis’, ‘recognising patient’s agency’, ‘team’s decision’ and ‘lack of external/community services’.

Conclusion The findings highlight areas for improvement to ensure equal access to specialist psychological support in hospice care, such as closer communication between hospice teams, psychological specialists embedded in multidisciplinary team discussions, psychological specialists providing feedback on referrals, and training and supervision to other hospice staff involved in patient care. Closer communication is needed between hospices and external organisations to provide better support for hospice patients in the community.