The National Health Service (NHS) is increasingly turning to charities to deliver frontline care, but this growing reliance is raising concerns about subsidising stretched budgets and exacerbating health inequalities.
A Lifeline for Patients
For dementia specialist nurse Louise Burns, the distress of a man on a video call was palpable. He was struggling to get his elderly mother, who has dementia, out of hospital and back home. Burns, part of a team running virtual clinics that support over 100 patients and families weekly, was able to reassure him. She explained the discharge process and where to seek help. Soon, his mother was back where she wanted to be.
Traditionally, such a service would have been run by the NHS, but this clinic, established during the Covid pandemic and continued due to high demand, is entirely funded by the charity Dementia UK. "The NHS and social care are under such huge pressure and dementia cases are rising - it's not always easy to get the support you need," Burns says. Paul Edwards, chief nursing officer at Dementia UK, adds that the charity is "trying to fill the gaps" within stretched NHS services.
Dementia UK is just one of many charities working in the health sphere. From children's care to mental health and cancer services, charities are playing an increasingly important role in caring for patients. Some, largely in England, have formal NHS contracts, while others work alongside the health service across the UK, providing additional support that the NHS cannot.
The Rise of Charity Involvement
Since the 1990s, governments of different parties have sought to develop a market of providers - NHS, private, and voluntary sector - making the charity sector big business in health. It's estimated that cancer charities alone raise more than £1bn a year, and the NHS in England spends nearly £2bn annually buying services from the not-for-profit and voluntary sector.
But concerns are mounting about the scale of charities' involvement in delivering frontline services, including from within the voluntary sector itself. Those directly providing services say they are having to subsidise squeezed NHS budgets. And despite good intentions, some critics argue that charity work with the NHS means more money ends up in wealthier communities. Defenders, however, say much-needed funding should be welcomed.
So is the growing role of charities a symptom of a health service at breaking point - or a positive way of involving the public in their health care? And what are the risks?
A Historical Perspective
Charities have long played a major role in UK healthcare. Before the NHS was founded in 1948, healthcare was provided through a patchwork of local charities, voluntary organisations, local authorities, and private arrangements. Many hospitals depended on charitable donations to survive. The creation of the NHS transformed this model, bringing most hospitals into public ownership and funding them through taxation. NHS founder Aneurin Bevan believed healthcare should not depend on charity, and restrictions were placed on NHS hospital charities actively raising money. But they did not disappear completely.
A major shift came with the Health Services Act 1980, which encouraged a more active fundraising culture. From then on, NHS charities expanded significantly and became increasingly professionalised. By the 1990s and beyond, they were raising substantial sums for equipment, buildings, research, and amenities like play areas in children's wards and well-equipped staff rooms.
Today, distinct from charities devoted to particular diseases or conditions, there are more than 220 NHS charities attached to hospitals or community services, raising £620m a year. Ellie Orton, chief executive of NHS Charities Together, says that while this sum may sound high, it represents only around 0.3% of the health budget. She argues that the purpose of these charities is to provide support, equipment, and services that are additional to what the NHS provides. Recent schemes include CPR training for the public, defibrillators in community venues, and green spaces in hospitals.
But it is a fine line. Scanners, blood transfusion equipment, and emergency department co-ordinators have also been funded by charities. Some would say core NHS functions like these are exactly what we pay our taxes for. Orton defends this: "It's just the way it is now. We shouldn't get too ideological about this. It's not helpful to think the state can do everything. Yes we pay taxes but that has to cover lots - and it's finite. If our fund-raising means a parent of an ill child can stay close to their child while they are in hospital in a room funded by a charity, why not?"
She says her discussions with the government suggest increasing interest in what charities can raise and what larger philanthropic donations can achieve. In recent years, huge one-off sums have been raised. During the pandemic, the NHS Charities Together Covid appeal received a £10m donation from trading firm XTX Markets, while the Rausing family gave £5m. Rugby league legend Sir Kevin Sinfield's fundraising for a specialist motor neurone disease centre at Leeds Teaching Hospitals brought in £6.8m.
"Of course, we are not talking about going back to a pre-1948 situation, but there is real interest in what such philanthropy can do," says Orton.
Inequalities in Funding
But there are inequalities. The NHS charity sector is dominated by some of the big London hospitals and specialist cancer and children's centres. The Royal Marsden and Great Ormond Street charities between them are responsible for nearly a sixth of the investment made by NHS charities. "This does concern us," admits Orton. "It's not always a level playing field, but the answer to that is to help the NHS charities that don't raise as much to raise more."
The legislation change in the 1980s, coupled with market reforms of the 1990s, also paved the way for specialist disease-specific charities such as Macmillan, Marie Curie, and Dementia UK to get involved in delivering NHS services. For example, over the past three decades, Dementia UK has developed a network of specialist dementia nurses known as Admiral Nurses, who work in various hospital and community settings. The model is based on the charity co-funding posts with the NHS for up to two years, with the expectation that the NHS will then take on the funding.
But with demand increasing, Edwards says it is becoming a "struggle" to get the funding needed from the NHS or from donations. "We are being asked to fund them for longer or find more than half the cost," he says. "Services are really being cut back."
And it is not just in dementia care that charities are noticing a squeeze. The charity WellChild has helped establish a network of 54 specialist nurses who work with very sick children. It funds these posts for the first three years, before responsibility is expected to transfer to the NHS. But for the first time this year, a nurse post was not kept on, says Amy Mitchell, WellChild's director of programmes. What's more, WellChild's nurses are meant to carry caseloads of 15, but the average is currently 40. "Services are being dismantled - and our nurses are propping things up," Mitchell adds.
Others in the voluntary sector agree. Charities are increasingly being asked to do more with less, says Mark Yates, chief operating officer of Rethink Mental Illness, "and there is too often an expectation that we will absorb shortfalls ourselves to keep essential services running".
Parkinson's UK told the BBC its funding has helped the NHS pay for around 70% of the specialist nurses working in the field, and its chief executive Caroline Rassell says it's unfair on people affected by the disease. "Charities having to fund these posts is effectively an additional 'tax' on people with Parkinson's as they are our main donors," says Rassell. "Nursing care should be the cornerstone of what the NHS offers."
Polling by the National Council for Voluntary Organisations (NCVO) shows 71% of health charities say the value of their contracts is not enough to meet the demand for the services they provide, with many using their own donations to keep them going. The survey dates back to 2023, but the NCVO says there is nothing to suggest the situation has eased. NCVO chief influencing officer Leigh Brimicombe says it's clear charities are having to "subsidise" the NHS and wider public services, and the government needs to address it by offering contracts that "cover the full cost of delivery". "Otherwise, we run the risk of services being reduced or cut completely, at a time that communities in need are relying on them most."
The NHS Perspective
For its part, the NHS is adamant that charities remain a valuable partner. NHS England points out that while the value of contracts to the voluntary sector as a proportion of the budget has dropped, it has still risen in cash terms. In a statement, NHS England told the BBC the current 10-year plan looks to build on the "potential" of these partnerships and give the sector a "stronger voice" in health and care.
It's a complex relationship, believes Helen Gilburt of the King's Fund think tank. Charities bring "real benefits" through their expertise and close ties to communities, she says, and there is "an element of subsidising" as the NHS seeks savings. But the situation has also "created inequalities" in the funding and support available for different diseases, she believes. For instance, some areas like cancer have an established charitable sector "which is able to attract large amounts of funding". These charities have been able to advocate for their patients, work with the NHS to enhance specialist services, and use their funds to develop services of their own. Then, she says, there are charities in some sectors - "Parkinson's and dementia are good examples" - which are investing their own funds to develop specialist roles. "But they would argue this does not go far enough to meet the needs of people they serve. Then there are other areas, like sickle cell disease for example, where the charity sector is small and has even less funding."
Inequalities exist within sectors, too, say experts. Take hospices, for instance. "The fact remains that some communities will be able to give more than others, leading to inequalities in hospice provision," says Toby Porter, chief executive of Hospice UK. And as a result, says Sarah Scobie, deputy director of research at the Nuffield Trust think tank, "more people from deprived areas die in the place where most people say they don't want to die - in hospital". Not all of these differences can be explained by fundraising capacity. Health literacy - people's ability to navigate services and advocate for themselves - can also affect access to support, she says. But her concern is clear - the scale of charity involvement in the NHS can widen inequalities.
As Orton points out, the UK is not returning to the pre-NHS era, when healthcare depended on charitable giving. Yet charities are no longer operating on the margins of the system, either.
