Vickie Flores/EPA
After the recent death of Captain Sir Tom Moore, outpourings of appreciation for his commitment to raising funds for the NHS during the pandemic have come from every corner of the UK.
Moore inspired people of all ages and from all backgrounds to give to charity. However, the scale of the funds raised – around £150 million – has also prompted questions about the role of charitable funding for the NHS.
Moore was one of a diminishing number of people with direct experience of the pre-NHS healthcare system. As a second world war veteran, he understood the risks and sacrifices ordinary people made at that time. These sacrifices directly influenced post-war promises to build a new and better Britain, including providing people with the security of a comprehensive health service.
Funding in the early days of the NHS
Before the NHS came into being, health services depended on what Aneurin Bevan (the first post-war minister of health) described as the “caprice of private charity”, where people’s chances of being treated by a voluntary (charitable) hospital varied fivefold between local authorities.
The NHS’s efforts to reduce unequal access in the post-war period were financed through taxes, national insurance and fees for some services. Charity played a largely marginal role.
Donations to NHS institutions were never formally banned. However, from the birth of the NHS until 1980, health authorities weren’t allowed to raise funds because it could lead to unbalanced service provision if some regions were able to raise more funds than others. The guidance suggested that gifts of money and equipment could be accepted, but charity shouldn’t be used to pay for items related to direct patient care, which was the government’s responsibility.
From 1980, restrictions on fundraising by health authorities were relaxed as part of initiatives by the Thatcher government to promote greater community support for public services. Since then, the NHS has seen more fundraising, but the outpouring of support since 2020 is unprecedented. Moore’s efforts encouraged fundraising across all ages, from 98-year-olds to young children.
Donations: a blessing or a curse?
Fundraising has divided opinion among a number of camps. One widely held view is that using charity for resources and staff and patient comfort is acceptable, which is broadly the NHS’s official position. However, some argue that supporting staff wellbeing is a public responsibility, which should include providing decent wages and working conditions without any need for charity. Others in favour of raising charitable funds to support healthcare service provision would remove restrictions on the use of donations altogether.
To put the issue in context, it’s worth summarising how much money is raised for the NHS through charities directly associated with individual NHS Trusts (the principal providers of healthcare).
When Moore launched his appeal, he stipulated that donations should go to an umbrella organisation called NHS Charities Together. The organisation is responsible for coordinating most of the funds generated by charity for the NHS and has over 200 member organisations.
Before the pandemic, these organisations were spending close to £500 million a year on NHS support. Even so, these sums don’t even add up to 1% of total public expenditure on healthcare in the UK. At best, this funding serves as “added extras” to the existing tax-funded system.
However, while many NHS charities are small in financial terms, that’s not the case for all of them. As Ellen Stewart, social studies of health and medicine researcher at the University of Edinburgh, has pointed out, they should not be dismissed as being marginally significant.
NHS charitable funds are spread very unevenly among communities and sectors of the NHS. Some major London teaching hospitals have received some of the largest donations of any British charity, and a number of NHS charities spend over £10 million a year.
There are also differences in the fundraising potential of different sectors of care. Charities associated with mental health or community health services generally receive far less fundraising income, which has led researchers to question how well charitable fundraising is aligned with health priorities. Despite substantial contributions to specific NHS institutions, less fortunate organisations or communities can be left out.
It’s possible that any increase in charitable giving may concentrate resources on parts of the NHS that are already well resourced. This isn’t a new issue. In 1848, political philosopher John Stuart Mill stated that “charity always does too much or too little. It lavishes its bounty in one place, and leaves people to starve in another.” The challenge for the NHS is balancing aspirations for providing equal access to care with the inequalities that arise as a result of voluntary fundraising.
There’s also the vexed issue about whether NHS fundraising is paying for services and facilities that should be the responsibility of the state. For many years, commentators have questioned the potential blurring of the line between supporting amenities and welfare on one hand and paying for core services on the other.
NHS staff receive public support because they’re working against the most dangerous threat to the nation since the second world war. But the public’s commitment to fundraising shouldn’t be seen as approval for transferring responsibility from the taxpayer to charity. If anything, recent events have reinforced public support for the NHS remaining a state-funded service for the entire population. The government should be very wary of assuming that support for appeals like Moore’s indicates otherwise.
John Mohan receives funding from the Wellcome Trust and the Economic and Social Research Council. He is a member of the advisory panel of the Centre for Health and the Public Interest.
Bernard Harris receives funding from the Wallenberg Foundation and the Wellcome Trust .