Border crossings: charity and voluntarism in Britain's mixed economy of health care since 1948

Our research programme will explore the empirical challenges to perceptions of the NHS as a unified state monolith, and analyse possibilities for effective, ethical and sustainable voluntary contributions to health systems.

Although conventionally understood as the archetypal statist health system, the NHS has always provided scope for voluntary initiative by citizens in the funding and provision of health care. Precise boundaries demarcating areas of statutory and voluntary responsibility have shifted over time and are often actively contested. 

While some practices at this boundary – for example volunteering, and the role of patient advocacy groups – have been widely-researched, this project centres on two neglected issues: the contribution of voluntary financial support for the NHS, and the position of institutions that remained in voluntary control or moved back to that status subsequently. We see developments in these fields as intriguing ‘border crossings’ with wider implications for perceptions of the appropriate limits of state and voluntary responsibility for health care.

There have been elements of continuity and change. In the NHS hospital and community care sectors, existing hospital endowments were largely retained (albeit under varying governance arrangements), while the Leagues of Friends provided a new avenue for fundraising as well as volunteering. Explicitly prohibited from the 1950s, in the 1980s fundraising by health authorities was permitted and a new age of appeals by individual institutions began. As for hospital ownership and control, after 1948 some voluntary institutions ‘disclaimed’ by the state continued in existence. In recent decades there has been a rising interest in alternatives to state ownership. This began through ad hoc transfers of NHS provision to the voluntary sector, and has been formalised with the more recent ‘spinoffs’ of parts of the NHS. 

This programme of work is generously funded by the Wellcome Trust through their Collaborative Awards in Humanities and Social Sciences scheme, with an award worth £1.4Mn over four years. 

Academic context

We will frame our research with reference to literature about the virtues and limitations of the voluntary sector. This encompasses both voluntary action by individuals (including charitable giving, and unpaid voluntary work) and voluntary organisations (usually, though not exclusively, registered charities).

Voluntary organisations are held to have distinct advantages, such as mobilising support for emergent societal concerns, overcoming trust failures arising from imperfect information, and promoting social innovation. Political science draws attention to wider societal benefits of voluntarism, particularly in relation to the generation of social capital, as individuals come together for a common cause. 

On the other hand, voluntarism’s weaknesses - tendencies towards insufficiency and inequities of supply, free-riding, inefficiency and paternalism - raise questions about its compatibility with comprehensive, statutory health services.  Empirical studies in this field focus on the conditions in which voluntary action waxes and wanes, the comparative virtues of voluntary and statutory providers of services, and the reasons for the mobilisation of voluntarism in political rhetoric. 

Research programme

The conceptual frameworks provide reasons for anticipating that the border between the voluntary sector and the healthcare state will be a porous and contested one, and they open up a range of issues for examination. We will study two relatively-neglected fields: the position of voluntary institutions, and voluntary fundraising, including the community activism that sustains it.  The project has five strands, each led by one of the collaborating partners: 

The intellectual and political evolution of policy towards voluntarism under the NHS (University of Strathclyde)

The establishment of the NHS marked a hugely-significant juncture, by bringing under state control the great majority of institutional services.  However, there has always been vigorous advocacy of alternative forms of both funding and provision. This strand therefore explores the development of political thought about the potential role for voluntary institutions in the provision of health care, drawing on a wide range of archival sources.

The development of endowed hospital charities since 1948-2012 (LSHTM)

This strand investigates the changing uses of the substantial charitable endowments retained by the teaching hospitals and administered first by hospital boards of governors and then under distinct trustee arrangements.  Three case studies (Cambridge, London, Scotland) are used to explore the changing policies and politics of charitable expenditure and its moving frontier with the state.

The history of the ‘disclaimed’ hospitals, and other third sector institutions moving in and out of the NHS (University of Birmingham)

We identify and trace organisations that were not nationalised, seeking to account for their adaptation (or otherwise) in the post-war context. We also investigate the successes and failures of organisations that have transferred out of the NHS more recently, either by continuing in existence under new voluntary ownership; or by reopening, but developing an alternative mission from that which guided them previously; or by moving out as ‘spinoffs’ of existing parts of the NHS.

Voluntary fundraising in support of the NHS since 1980 (University of Birmingham Birmingham)

The 1980 Health Services Act empowered health authorities to engage in local fundraising. Using financial statistics from the early 1980s onwards, we examine trends and variations between communities and institutions in fundraising, and their relationships to patterns of NHS funding. Results of this work will also support projects 2 and 5. Case studies of key individual initiatives are used to explore policy and practical dilemmas in depth.

Contemporary organisational and decision-making structures in NHS charities (University of Edinburgh)

The contemporary picture of NHS charities is changing rapidly. A nationally-coordinated fundraising campaign was launched to celebrate the NHS’s ‘70th birthday’ in 2018, but some recent controversial decisions concerning the expenditure of charitable funds pose anew the question of the boundary between statutory and voluntary initiative. Building on pilot fieldwork already conducted, this strand will deploy organisational ethnography to explore how a range of NHS charities negotiate these borderlands through their fundraising and spending decisions.

Significance of the research

On some economic measures (value of endowments, funds raised or annual spend), the charitable initiatives we will investigate are substantial in their own right. However, our study goes beyond straightforward quantification of that contribution and acknowledges that the initiatives we study also provide important non-economic societal benefits, such as supporting innovation, while the blurred boundary with statutory funding raises challenges for policy. An examination of the scale and impact of these activities and resources is of significant relevance both to academic scholarship and the public interest.

While unanticipated at the time we submitted our funding application, the project is highly timely given the recent attention to charitable fundraising around the COVID-19 epidemic.


John Mohan

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