Charitable Health Service

Agnes Arnold-Forster

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.


  • 12 February 2022 at 3:04pm
    XopherO says:
    Hard to disagree, but what to do? It is currently a massively underfunded mess, and those who start to work in the NHS because of a sense of public service can become quickly disillusioned. Nurses are regarded as second class to doctors and often at their beck and call. They wear different clothes to distinguish the hierarchy. Support staff like porters are at the bottom. The founding of the NHS was opposed by doctors and the BMA, and they had to be bribed with the option of some private practice (very expensive in the UK) by Bevan. I don't think the BMA has ever really accepted the NHS, and many of its decisions and activities have been hardly helpful. The idea that the UK has done best during the pandemic is belied by the massive waiting list and xs deaths. UK 210/100k, France119/100k. Why? because France's much better funded system has more beds, more doctors per capita, and most routine consultations and procedures went ahead with little delay ( I know that from personal experience) and so there have been many fewer non-Covid deaths caused by delays or patients not seeking help. But of course, France's system is not free-on-demand (except for the chronically sick and those on social security) You have to pay 30% of the costs of all out-patient/GP services (not in-patient). Most people take out insurance through a 'Mutuelle' to cover the 30% and other costs not covered by the state. So there is the rub: how does the UK get up to a level of funding, provision and efficacy like France and some other EU countries? Certainly not through privatisation on a US model - 293/100k - which is where this corrupt government is going.

  • 13 February 2022 at 12:39pm
    David Lobina says:
    The article hints at the problem with charity and volunteerism, which is much more common in the UK than in many other countries (or so it seems to me) - namely, the fact that charity and volunteerism are there to patch over a failure of the state to begin with, and thus, that they are not quite the right solution and in fact not an entirely positive phenomenon. Or looked at from the other direction: many other countries don't have this level of charity because there are not as many gaps in health and social provisions, and that's certainly better.

    By the way, it is common to go on about how much the British love the health service, and to state that this sentiment is stronger here than in other countries with similar arrangements, but I would love to see the evidence for this. My background is Italian and Spanish (but born in the UK), I have lived for long stretches of time in each country and I doubt that the British love their health service more than the Italians or the Spanish do theirs.

    • 13 February 2022 at 3:54pm
      XopherO says: @ David Lobina
      I agree entirely, ditto France. One of the problems with the NHS is that it is apparently 'the best in world' when patently not, at least since the 1960s. This best in the world mantra actually hinders proper investment and modernisation. If everyone is persuaded it is the best, no need to invest - very convenient. Blair saw the light in 2000 when the WHO survey came out placing the NHS as 19th in the world - not bad, but hardly 'the best', though at the time he claimed the UK was the 5th richest nation. Unfortunately he threw money at it without any real analysis and planning, and now the funding has declined back to around that 2000 relative level, and the chickens are coming home to roost in terms of cancer survival, perinatal mortality (even worse for black women), infant sickness and mortality, waiting times, poor training by the top standards etc. Yes, it has got better, but so has it in comparable countries, and the UK languishes towards the bottom of the stats for developed nations.