Charitable Health Service
When Captain Tom Moore set out with his walking frame at the beginning of April 2020, he had a moderate goal. His plan was to walk up and down his garden 100 times before his 100th birthday, and in the process raise £1000 for the NHS. One of his daughters, Hannah Ingram-Moore, thinking it might make the local news headlines, got her consultancy firm to put together a press release.
Three days later, Captain Tom was live on BBC Breakfast. By 20 April he had raised more than £20 million. The Captain Tom Foundation was set up in May 2020, and has raised another £1 million. By the time he died, in February 2021, Captain Tom had been knighted, released a number one single, and raised £32.8 million for NHS Charities Together.
Over the last few days, however, it has emerged that the foundation set up in Captain Tom’s name (not NHS Charities Together) not only paid out more in management costs than it did in grants during its first year, but also paid over £50,000 to two companies run by Ingram-Moore and her husband. The revelation has provoked outrage. But more illuminating, really, is what happened to the £33 million that Captain Tom raised himself, and what it tells us about the NHS’s increasing reliance on charitable giving.
The donations were delivered to the 241 members of NHS Charities Together in two tranches. In the first, each received £35,000. The second round of funding was distributed according to the number of staff each hospital trust had on its payroll, with the final allocation working out at roughly £7 per worker. Hospitals could choose how the money was spent: a new staff shower block, a leadership course for nurses, iPads for patients to speak to their distant loved ones, sandwiches, drinks, energy bars, lip balms, hand creams, lockers, counselling services.
Before the founding of the NHS, many hospitals relied on charity. Some, especially if they were in large cities or dedicated to specialist care or vulnerable populations, accumulated vast endowments. The Ministry of Health made a fractious compromise with the management of these wealthy institutions, allowing them to keep their endowments after 1948 on the condition that they didn’t spend the money on ‘core’ NHS services. Instead, they were expected to fund medical research, and pay for non-essential staff and patient ‘amenities’ such as Christmas parties, flowers for the long-stay wards, and retirement gifts for loyal workers.
Almost immediately, however, the boundary between state and charitable funding was blurred. And in 1980 the rules changed, loosening the restrictions over what these incredibly wealthy institutions could spend their money on. Since then, charity has funded an ever larger proportion of NHS services.
Many of the things that the money raised by Captain Tom was spent on fall into the ‘amenities’ category – free fruit for staff at London’s Charing Cross Hospital, or free mineral water for nurses at Wrexham Maelor Hospital – but some of it went on baby monitors and blood pressure machines.
The spending of this money isn’t a scandal. Hospitals and NHS Charities Together worked within the rules and used the unexpected cash to provide their staff and patients with what they thought they needed most. But it is a troubling indicator of quite how reliant the NHS now is on charitable giving. The British public have a remarkable emotional investment in their health service. The high feelings this arm of the state evoke are unusual by comparison to other nations – even those whose health services are similarly free at the point of access – and they have intensified over time. Some of the things that people love about the NHS are practical and self-evident – it’s good to not have to worry about money when you’re very sick – and some of them are more abstract and ideological.
The NHS is supposed to be a state-funded service. It is supposed to be funded through taxation and we know this is important to people because of the ire and frustration prompted by privatisation. But the idea that the NHS is a state-funded service has never been entirely true.
There’s a difference between charity and private companies operating for profit. But that doesn’t mean charity is without its flaws, both ideological and practical. It is difficult to distribute evenly and equitably. The NHS is supposed to be a ‘national’ service – providing the same care to everyone, regardless of where they live. We already know that ideal isn’t met (the ‘postcode lottery’), and charity makes it even harder to achieve. The super-wealthy hospital charities are all in big cities. Charities also tend to funnel money towards some populations and conditions, and not others. Cancer charities and children’s hospitals – though hardly undeserving – get a lot more money than their less emotive counterparts.
Charity is also incapable of addressing large structural problems. Much of the money raised by Captain Tom went to staff who have had a terrible time during the pandemic. But their experiences are due not only to the unique conditions of Covid-19, but to fundamental problems with the way the healthcare workforce is managed. There are also deep-seated cultural issues in medicine and nursing that make bullying, harassment, and mental ill-health rife. The snacks, comfy chairs and mineral water were no doubt appreciated, but hardly the radical transformation that NHS staff need or deserve.
But perhaps the trickiest thing about charity in the NHS is the way it absolves the government of responsibility. The NHS doesn’t only need money; it needs well-planned, well-spent money, that can be used to make big, substantive changes to the way the service works. Charities cannot provide the volume or kind of cash required, and cultivating a dependence on donations risks sending a message to government that exchequer support is no longer necessary. If we want the NHS to remain a state-funded service, then it needs to become one.