Background Current UK agendas for end of life care advocate ‘timely specialist palliative care’ and ‘effective’ hospices that are ‘responsive to people’s needs’. Hospices need to maintain capacity for admissions, whilst facing increasing demands from a rapidly growing, multimorbid, complex population. Hospices cannot afford to accommodate protracted lengths of stay. We aimed to identify patient and service factors associated with hospice in-patient longer lengths of stay (LLOS), 21 days to enhance our ability to provide quality, effective and equitable care.

Methods Mixed methods: Retrospective cohort review of all LLOS admissions in 2015, analysing sociodemographic and disease variables contrasted against a retrospective case-control analysis of admissions totalling 7–20 days. This was complemented by a retrospective case-control, thematic analysis of electronic patient records, to examine the patient journey throughout the duration of the hospice stay.

Results LLOS admissions accounted for 23%(76) of admissions to our hospice in 2015 (2342 bed days), median stay 28 days, 55% female, median age 69 years, 96% (73 admissions) referred for symptom control. Admission outcome: 38% (29) of patients discharged, of which 59% (17) had a new care arrangement following their stay.

No significant findings when analysing the following against LLOS admissions and admission outcome: Patient age, gender, primary diagnosis, number of comorbidities, presence of formal social care support, and permanent residence.

Thematic analysis identified 4 overarching themes implicated in LLOS: Uncertainty, In-house interventions, clinical and social complexity. This analysis emphasised, in particular, the interplay between communicating and managing uncertainty and social complexity.

Conclusion Our results would suggest that there are no sociodemographic or disease factors associated with LLOS. Thematic analysis provides an alternative and successful method of service evaluation. Thematic results emphasise the need for research into managing complexity and uncertainty in addition to highlighting the fact that our growing capacity to provide in-house interventions comes, ultimately, at a cost to bed availability.