The place of charity in a public health service: Inequality and persistence in charitable support for NHS trusts in england

The British National Health Service (NHS) relies for the great bulk of its funding on direct taxation, but the contribution of charitable sources of income to the NHS is not well-understood. The few studies of charitable giving to the NHS to date have concentrated on aggregate levels of income and expenditure. However, to date there has been limited collective understanding about the extent to which different kinds of NHS Trusts benefit from charitable funding and about the persistence of inequalities between trusts in their access to these resources. This paper presents novel analyses of the distribution of NHS Trusts in terms of the proportion of their income that comes from charitable sources. We build a unique linked longitudinal dataset which follows through time the population of NHS Trusts, and the population of associated NHS charities, in England since 2000. The analysis illustrates intermediate levels of charitable support for acute hospital trusts compared with the much lower levels of charitable support for ambulance, community and mental health Trusts and, conversely, much higher levels of charitable support for Trusts providing specialist care. These results represent rare quantitative evidence relevant to theoretical discussions about the uneven nature of the voluntary sector's response to healthcare need. They provide important evidence for a key feature (and arguably weakness) of voluntary initiative, namely philanthropic particularism - the tendency for charitable support to focus on a restricted range of causes. We also show that this 'philanthropic particularism' - reflected in the very sizeable differences in charitable income between different sectors of NHS trusts - is becoming more marked over time, while spatial disparities, notably between elite institutions in London and other locations, are also substantial. The paper reflects on the implications of these inequalities for policy and planning within a public health care system.