The NHS allows scope for voluntary financial support of its institutions, and large numbers of people are motivated to engage in fundraising activities for NHS institutions – as witnessed during the early phases of Covid-19. Although most health care providers were absorbed into the NHS when it was established, scope remained for private provision of services by charitable organisations outside the NHS. Our project is concerned with the distinctive contribution these organisations and activities make, and the challenges they pose for policy. The work packages we are developing encompass these issues as well as the role of charitable support in innovation in health care delivery, the importance of voluntary action in engaging the public in supporting local health services, and the significance of voluntary organisations in their communities.
The impact and significance of ideas about the importance of voluntary action in the development of health policy in the UK after 1948
This theme is designed to provide an overall framework for understanding the development of public policy in relation to voluntarism and health care since 1948. As such, it is directly related to each of the other four themes which together constitute the Border Crossings research programme.
It will examine the relationship between voluntarism and health care in the years immediately prior to the creation of the National Health Service, during the period of the so-called ‘classic’ welfare state between 1948 and 1979, and in the years since. It will focus on issues relating to the development of ideas associated with the boundaries between statutory and voluntary responsibility and on different aspects of the role of voluntary action in the provision of health care. It will also look at issues relating to charitable funding, the regulation of charitable involvement, and the coordination of statutory and voluntary initiative, and it will aim to explore each of these issues across the whole of the United Kingdom, including not only England and Wales, but also Scotland and Northern Ireland.
We aim to address these issues by looking at a wide range of source material, including papers generated by medical pressure groups and independent think tanks; articles in the medical and health-service press; official papers; papers generated by political parties and voluntary organisations; and interviews with former policy-makers and administrators.
Principal Investigator: Bernard Harris
Institutions on the border between statutory and voluntary control
Although most institutions transferred to the NHS in 1948, approximately 200 did not. Conversely, numerous hospitals have subsequently (and mostly since the early 1980s) transferred out of the NHS, reconstituting themselves as independent charities. No study exists of the experience of either type of these institutions. The surviving disclaimed hospitals were noted briefly in discussions of market structure in the private health sector. Previous research has also identified a small number of hospitals that reverted to charitable control, mainly small community hospitals, but no study has systematically investigated how such organisations have developed subsequently.
The development of both categories of institutions can shed new light on the tensions which surrounded the foundation of the NHS and illuminate the practical problems caused by the continuing need to coordinate the activities of these institutions with the state system. We will use case studies to illustrate the range of experience of different types of institutions – from small-scale community hospitals returned to voluntary ownership, up to institutions which remained outside the NHS and have become (in financial terms) among the largest charities in the UK. These are unusual cases: their survival was arguably not anticipated and so consideration of their development has much to tell us about their roles (the articulation of their distinctive contributions to health care delivery), resources (how they secured funding) and relationships (how they negotiated the very different policy and funding environment of the post-1948 NHS). This strand of our work thus responds to calls for more work on the persistence and durability of voluntary activity in apparently unpromising conditions. It also contributes to debates in voluntary sector scholarship regarding the advantages or disadvantages of charitable initiatives?
Our research questions include consideration of the circumstances in which these institutional moves take place; how voluntary institutions outside the NHS articulated a distinctive niche; the strategies which they developed to secure resources; and the relationships they developed with NHS authorities, regulators, and other non-NHS interest groups.
Principal Investigator: John Mohan
The impact of endowed hospital charities on practice and policy in the NHS, 1948-2018
This theme analyses the administration and allocation of charitable hospital endowments under the trusteeship of NHS bodies. Many pre-NHS voluntary hospitals accumulated ‘endowment property’ to support current and capital expenditure. This came through bequests or donations,typically of property, cash, gilts or stock, and by 1948 formed a substantial wealth base.
Debate about its disposal under the NHS was resolved through Bevan’s compromise with clinical elites. English teaching hospitals and their local affiliates would remain independent of NHS Regional Hospital Boards (RHBs) and thus retain control of their charities. The associated funds were managed by their Boards of Governors before 1974 and then by separate trustees. The Scottish legislation was different, bringing all hospitals and their charities under the aegis of the Scottish RHBs, with a Scottish Hospitals Endowments Research Trust (SHERT) established to guide policy. For both, their nominal remit was amenities for patients or staff, or useful medical research, rather than curative services which were now publicly financed.
From the 1980s, hospital charity governance was liberalised, with fundraising permitted for capital and developmental projects. Following the coming of the internal market and the conversion of hospitals to foundation trusts, it became normal for substantial charitable funding to be expended on buildings and services, in addition to medical research. By 2000, some hospitals, particularly teaching and specialist units, retained substantial capital wealth which conferred particular advantages over their peers. The estimate (quoted previously) of annual spending of £500Mn by NHS charities is not large but, in context, it is likely that much of it supports expenditure on buildings or equipment, so a more appropriate comparator is public capital expenditure of c.£5.9 billion.
A preliminary descriptive question will lay the groundwork for three interrelated analytical questions:
- How did hospitals and charity trustees organise to manage their funds and allocate their proceeds?
- Did the allocation of charitable spending continue pre-NHS patterns favourable to elite curative institutions, or prioritise development of affiliated special and ex-municipal hospitals?
- To what extent did the charities further medical innovation, and how important were individual policy entrepreneurs?
- How did these charitable activities influence NHS capital planning in the surrounding region?
The research design is a comparative historical analysis of endowed hospital charity administration since 1948 in three case-study settings: East London (St Bartholomew’s, the London), Cambridge (Addenbrookes), and Glasgow/Clydeside.
The English cases represent early metropolitan and provincial foundations with substantial asset bases both in 1948 and today. The Scottish case allows proper comparison with the English administrative structure, viewed through Scotland’s largest city. All cases represent teaching hospitals clustered with special and ex-municipal institutions. More pragmatically, selection followed preliminary scoping confirming comprehensive, catalogued sets of records in the public domain.
Data collection methods will be primary documentary research in relevant repositories, supplemented, for the recent period, with oral history. We will convene two three-hour witness seminars (of cross-cutting relevance to other WPs), one addressing charity policy since the internal market (and also drawing on work done in relation to RQ1.3), the other examining fundraising appeals. 20 one-hour oral history interviews with key participants (trust managers, medical innovators and fundraisers, voluntary trustees) will be held, with rosters developed through snowball sampling.
Principal Investigator: Martin Gorsky
Contemporary charitable fundraising and the NHS
The initial prohibition on direct fundraising by NHS hospital authorities was eventually removed. The decision to do so was controversial – some commentators feared the effects on the wider population of charities of appeals for funds by the NHS. There are several hundred NHS charities and of course their profile has increased greatly thanks to fundraising efforts during the Covid pandemic. In research terms this is a neglected area: we lack systematic analyses of changes in these funds over time, their distribution, and relationships to NHS expenditure.
We will explore the following topics:
- Variationin the distribution of charitable resources between communities (e.g. according to differences in prosperity) and between types of NHS Trust (e.g. teaching hospitals, general acute trusts, mental health, community care).
- Trends in the amount and distribution of these funds since 1980? How do these changes relate to aggregate trends in NHS resources and the resources of individual NHS Trusts?
- How do trends in NHS fundraising compare with trends in the resources of the wider population of charities?
- How are charitable funds used within the health sector? What is the apportionment of funds between capital investment, research, patient amenities, and other categories? Key points here concern the boundary between what is the responsibility of the NHS and what is not – a point raised by analyses of the legal position of NHS charities and the implications for NHS strategic planning of the availability of significant fundraising income.
Quantitative analyses of distribution and trends, working on previously-unused statistical sources from the Department of Health, answers to Parliamentary Questions from the 1980s, and records from the Charity Commission. This will be complemented by analyses of organisational documents for further detail of sources and application of funding. A subset of cases will be chosen for further, qualitative investigation, including interviews with key stakeholders, based on the outcomes of quantitative analyses.
Principal Investigators: John Mohan and Diarmuid McDonnell
The work of contemporary NHS charities
In this project we explore the contemporary work of NHS charities at the boundary of statutory and voluntary initiative. The COVID-19 pandemic prompted a major, and exceptionally successful fundraising campaign from NHS Charities Together. Raising over £140 million, and making Captain Sir Tom Moore a household name, this campaign demonstrated the depth of public support for the NHS, and its staff.
However relatively little academic research has been undertaken into how NHS Charities operate at the boundary between state and charity. The formal regulatory environment for NHS charities has shifted in the 2010s, and it continues to vary across the UK. While relevant in shaping organisational decisions, this research takes as its starting point that local NHS charities are nonetheless diverse and seeks to understand the emergence and implications of this diversity. Some are strategic and ambitious actors, taking on significant roles in funding revenue costs and capital projects as well as the promotion of volunteering. These larger NHS charities, with significant existing endowments, have attracted some research attention. Far less consideration has been given to the vast majority of NHS charities: either tiny organisations which are entirely reactive, staffed only by part-time contributions from existing NHS finance staff and operating with what is described as a ‘bank and thank’ model of fundraising; or medium-sized charities seeking to move beyond this model.
Building on the quantitative analysis of the work done in Contemporary charitable fundraising and the NHS, this research will explore the shifting contemporary work of NHS charities in England, Scotland and Wales.
- How do different models of NHS charity emerge in consistent regulatory environments?
- What types of knowledge and expertise do NHS charities draw on when making spending decisions, and how do they evaluate their spending?
- How do NHS charities communicate with the wider public? Does their work reshape NHS organisations’ relationships with the public?
- How do fundraisers and donors understand the role of NHS charities vis-à-vis a) statutory funding and b) other local charities?
Principal Investigator: Ellen Stewart