The fundraising of Captain Tom Moore and many others during the coronavirus outbreak has propelled charitable giving to the NHS into the public eye. At the time of writing, NHS Charities Together had raised over £100 million for its emergency Covid-19 appeal “that acknowledges and supports NHS staff and volunteers caring for COVID-19 patients”, with over £32 million of this raised by Captain Moore’s sponsored walk alone. However, this feat has also prompted a backlash in some quarters, including concerns that donations are masking underlying long-term underfunding of the NHS, and that philanthropic giving more generally has deleterious democratic consequences. Both the unprecedented scale of this fundraising, and the pressing question of how the money will be spent, need to be understood in their historical context, and within wider debates on the ‘mixed economy of welfare’ and the role philanthropy can and should play in meeting public needs.

A first point is simply to contextualise the fundraising within total NHS budgets. Comparative figures with other countries vary depending on how much social care and long-term care is included, but the UK spends about an average amount of its GDP on health compared to other European health systems. Nonetheless, the figures can be startling in black and white: in 2017 the UK as a whole spent £197 billion on healthcare. That makes £100 million look less like a threat to the taxation-based funding of the NHS and more plausible, as NHS Charities Together argue, as an embellishment of ‘added extras’ to the existing tax-funded system.

Second, NHS charities are far from new, and certainly not a vehicle created by the current Westminster Government to advance the creeping privatisation of the NHS. Many have existed since the creation of the NHS, and often grew out of charitable funds that predated it. In one speech Bevan declared that the fledgling NHS needed “all the voluntary help we can get”. In practice, charity was strictly limited (in another speech he declared it “repugnant to a civilised community for hospitals to have to rely upon private charity”) but the charitable endowments remained in existence and some grew. That is not to say that they have not changed over time. NHS fundraising has always been a fairly vexed policy issue and governmental enthusiasm for the NHS charities has waxed and waned along with concerns about the governance of the charities. More generally, the NHS has rarely been a monolithically tax-funded healthcare system. The briefest glance at the financial position of hospice care in the UK, for example, puts paid to the idea that as a country we are outraged by vital services relying on charitable pounds.

Third, some of the debate about NHS charities has become embroiled in wider debates about ‘big philanthropy’, with key advocates of organisations like the Gates Foundation defending their role, while others critique their unaccountable power in the world as a threat to health governance worldwide. Far from being excessively influential, NHS charities, with the exception of a handful of the major teaching hospitals, are tiny, local charities. ‘NHS Charities Together’ operates as an umbrella organisation with a small staff. That doesn’t mean we shouldn’t question the governance of these significantly increased funds, but that we should distinguish the right questions to ask.

There are valid critiques of the role of charities within the NHS. The funds are spread very unevenly across the country in geographical terms. The big London teaching hospitals function with large historical endowments and few others outside the capital can compete with their brand awareness. There are also differences in the fundraising potential of different sectors of care, such as mental health trusts or addiction services. This is especially problematic when we consider the potential of charitable donations in England’s fragmented NHS, as compared to the Welsh, Scottish and Northern Irish territorial boards. This inequality also exists, of course, beyond the narrow parameters of what has conventionally been seen as ‘the NHS’. We should ask why social care services (almost all run by the private sector) and indeed, preventative public health measures tackling the wider social determinants of health, languish without nearly enough funding from any source. In the last few weeks we’ve seen repeated calls to enlarge our ‘clap for the NHS’ towards a more expansive ‘clap for carers’. However the financial corollary of this doesn’t exist for social care. NHS Charities Together, who launched their first ever nation-wide fundraising campaign in 2018, has been perfectly placed to capitalise on current public outpourings of gratitude for ‘the NHS’.

‘The NHS’ stands in, as it always does, as placeholder for a myriad of public hopes, fears and thanks in our current crisis. Reflecting on #clapforcarers last week, Gary Younge eloquently centers the role of Black and Minority Ethnics immigrants in sustaining and dying working in the NHS; “clearly, we’re not all clapping for the same thing”. A recent paper by Des Fitzgerald and colleagues explores the role of the mythologised NHS in the 2016 Brexit campaign. In order to understand the meaning and consequences of current exceptional patterns of public donation to the NHS, we will need to explore the work of NHS charities in practice, and how members of the public understand the cause to which they are donating. A new Wellcome Trust Collaborative Award, granted before the covid crisis but now more pressing than ever, seeks to do just that. Starting this autumn, we will take a wide historical lens and draw on insights from a range of disciplines across the social sciences and humanities to rethink the past, present and indeed future of charitable giving in the NHS.