When dementia specialist nurse Louise Burns took a video call from a distressed man trying to bring his mother home from hospital, she was able to guide him through the discharge process. The virtual clinic she works for, set up during the pandemic and continued due to demand, supports over 100 patients and families each week. But it is not run by the NHS—it is entirely funded by the charity Dementia UK.
The clinic is one example of how charities in NHS care are taking on a growing role, from children’s services to mental health and cancer support. While some have formal contracts with the health service, others work alongside it to provide help the NHS cannot. This shift has sparked debate about whether it is a pragmatic response to a stretched system or a risky patchwork that masks deeper problems.
A long history of charity involvement
Before the NHS was founded in 1948, British healthcare relied heavily on charities, voluntary organisations and private arrangements. The creation of the NHS brought most hospitals into public ownership and funded them through taxation, with founder Aneurin Bevan insisting that care should not depend on charity. Restrictions were placed on NHS hospital charities raising money, though they could still receive gifts.
The Health Services Act 1980 encouraged a more active fundraising culture, and by the 1990s market reforms opened the door for specialist charities like Macmillan, Marie Curie and Dementia UK to deliver NHS services. Today, more than 220 NHS charities are attached to hospitals or community services, raising £620m a year—about 0.3% of the health budget, according to Ellie Orton of NHS Charities Together.
Filling gaps or subsidising shortfalls?
Dementia UK’s chief nursing officer, Paul Edwards, says the charity is “trying to fill the gaps” in stretched services. But the model often involves co-funding posts with the NHS for up to two years, with the expectation that the NHS will then take over. Increasingly, that handover is not happening. Edwards says it is becoming a “struggle” to secure NHS funding, and services are being cut back.
WellChild, which funds 54 specialist nurses for seriously ill children for the first three years, saw a post dropped by the NHS for the first time this year. Its nurses are meant to carry caseloads of 15 but average 40. “Services are being dismantled—and our nurses are propping things up,” says Amy Mitchell, the charity’s director of programmes.
Parkinson’s UK says its funding has helped pay for around 70% of specialist nurses in the field. Chief executive Caroline Rassell argues that this amounts to an additional “tax” on people with Parkinson’s, who are the charity’s main donors. “Nursing care should be the cornerstone of what the NHS offers,” she says.
Polling by the National Council for Voluntary Organisations (NCVO) found that 71% of health charities say the value of their contracts is insufficient to meet demand, with many using their own donations to keep services running. The survey dates from 2023, but the NCVO says nothing suggests the situation has improved.
Inequalities in funding and outcomes
The charity sector is not evenly distributed. NHS charity investment is dominated by large London hospitals and specialist centres; the Royal Marsden and Great Ormond Street charities together account for nearly a sixth of all NHS charity spending. Orton acknowledges this is a concern but says the answer is to help smaller charities raise more.
Helen Gilburt of the King’s Fund think tank believes the relationship brings “real benefits” through expertise and community ties, but has also “created inequalities” in funding across diseases. Cancer charities, for example, attract large sums and can advocate for patients and enhance services. Others, like Parkinson’s and dementia, invest their own funds in specialist roles but argue it is not enough. Sickle cell disease has a small charity sector with even less funding.
Geographic disparities matter too. Hospice UK’s Toby Porter says some communities can give more than others, leading to inequalities in hospice provision. Sarah Scobie of the Nuffield Trust adds that more people from deprived areas die in hospital—the place most people say they do not want to die—and that health literacy also affects access to support.
A partner, but on what terms?
NHS England insists charities remain a valuable partner. It points out that while the proportion of the budget spent on voluntary sector contracts has fallen, the cash value has risen. A current 10-year plan aims to build on the “potential” of these partnerships and give the sector a “stronger voice.”
Yet the concerns are mounting. Charities are being asked to do more with less, says Mark Yates of Rethink Mental Illness, with an expectation that they will absorb shortfalls. The NCVO’s Leigh Brimicombe calls for contracts that “cover the full cost of delivery” to avoid services being reduced or cut altogether.
As Orton notes, the UK is not returning to a pre-NHS era, but charities are no longer on the margins either. Their growing role raises uncomfortable questions about what happens when the safety net is woven from voluntary threads—and who gets left out when those threads run short.
