Survey: Gift-giving in the NHS

As we launch our new survey on gift-giving in the NHS, we take a look at the many meanings gifts can carry and why they might be important to look at in the history of the NHS.

bevan-and-jennie-leeMy colleague Natalie pointed me to a story in Jennie Lee’s My Life with NyeAlthough she was a forceful socialist politician in her own right, she is often remembered more as the wife and widow of Aneurin (Nye) Bevan, the health minister who founded the NHS:

“There was a strict rule in Nye’s Ministry that any unsolicited gifts sent to him should be promptly returned. On one occasion, and only one, an exception was made. Nye brought home a letter containing a white silk handkerchief with crochet round the edge. The hanky was for me. The letter was from an elderly Lancashire lady, unmarried, who had worked in the cotton mills from the age of twelve. She was overwhelmed with gratitude for the dentures and reading glasses she had received free of charge. The last sentence in her letter read, “Dear God, reform thy world beginning with me,” but the words that hurt most were, “Now I can go into any company.” The life-long struggle against poverty which these words revealed is what made all the striving worthwhile.”

The giving of gifts has been a common ritual over the seven-decade history of the NHS, whether that’s giving tokens of gratitude to the staff or simply bringing in something for a patient to pass the time while they’re stuck in a hospital bed. Yet it’s an everyday feature of the NHS’s history that’s likely to be forgotten in time. When a large charitable donation is made or a charity provides equipment for a hospital that is likely to be recorded, and of course a gift to a health minister might get a mention in a political memoir. But there’s likely to be no paper trail to find out about the box of chocolates, flowers or thank you card given to the nurses on the ward.

Such displays of gratitude are important. Not just because they are a tangible part of the human interactions at the heart of the NHS on a day-to-day basis, but because they reveal something about what we think of the NHS itself. It’s not standard practice to give a gift anytime medical treatment is received, so we have to ask why it happens when it does. Much of the time, it’s a recognition that a patient or family member thinks of the staff as having gone above and beyond what’s expected. There’s plenty of paperwork to accompany formal complaints, at least in recent years, and thank you gifts are their positive and easy-to-overlook counterpart.

Hil - locker giftsIn a health service that doesn’t (usually) take payment, the fact that people often want to give something back speaks volumes about our relationship with the NHS. This might be a small token of thanks to the nurse or the doctor, but might be about giving back to the institution. We don’t know a huge amount about fundraising for NHS hospitals, for example, but sponsored marathons and the like often seem to be inspired by giving back after a family member has received quality care from the NHS.

Of course, there may be other reasons for giving gifts too. One former nurse told me that when she worked in one maternity hospital it was common practice for the expectant father to give a gift to the nurses when his wife was brought in. Not as a thanks for a job well done, but as a “bribe” to look after her properly.

And we should remember that gifts are not always given to the NHS, its institutions or its staff. Patients in hospital wards might be brought a bag of grapes, bunch of flowers or a pile of magazines to pass the time. And gifts of this kind can also tell us a lot about the NHS. It gives us an idea of what might not be provided – or what people might not expect to be provided – by this ‘comprehensive’ health service. While nobody would imagine the NHS would provide the latest issue of Take a Break, it did surprise me to find bedside cabinets (pictured) being gifted to hospitals by a charity in the 1970s.

In all kinds of ways, then, the NHS is daily the site of gift-giving. And that deserves to be part of how its history is written.

Click here to fill in our anonymous survey and help us include stories of gift-giving in our people’s history of the NHS

Learning to pay for the NHS: Students, Universities and the NHS Surcharge

Across the UK in the next few weeks, universities will welcome thousands of new and returning students, many of them coming from abroad. These students have been actively recruited by Britain’s higher and further education sectors, and almost universally pay higher fees than their UK and European Economic Area [EEA] counterparts. But they pay other fees as well: for instance, unlike tourists, business travellers, EEA students, and non-resident British expats, non-EEA students (like other non-EEA migrants entering the UK for more than six months) have since April 2015 paid what is call the ‘Health Surcharge’: a fee of £150 per year, paid up-front for the entire duration of their student visas. Indeed, according to the National Union of Students, the circa half a million non-EEA students make up 75% of those to whom the surcharge is applied.

When this new fee was introduced by the Conservative/Liberal Coalition government, British ambassadors around the world scurried to explain it to key student-sending nations. Charles Hay, Britain’s ambassador to South Korea, for example, acknowledged the ‘very valuable contribution’ made by Korean students to the UK economy. In recognition of this, he said, Britain had ‘deliberately kept this surcharge at a competitive level – lower than most private health insurance policies’ required by ‘our competitor nations’. Additional dependents accompanying the student would each pay the same charge, and there was no reduction in the charge for students coming from lower-income nations. Mike Harper, Minister for Immigration at the time that the Health Surcharge was added to the 2014 Immigration Bill, took a slightly different line, asserting, ‘We have been clear that the UK has a national health service not an international health service’ (not a novel claim – it has regularly surfaced in various forms since 1948 – though one for which the 1946 Act establishing the NHS offers no support): the charge, he added, merely represented a ‘fair contribution to the costs of the health service’.

Politicians justified the new surcharge on the basis that ‘international students’ cost the NHS £430 million per year, or around £700 per head. Notably, this is less than half of the cost estimated per head for British expats who return to the UK for free NHS treatment despite living abroad, to whom the charge does not apply (not least because it could not be collected alongside visa fees). In fact, it is an intriguing figure for many reasons: first, since the very earliest days of the NHS, auditing the cost of ‘health tourism’ has proven to be an almost impossible challenge – for more on this murky area, see reports from Full Fact and this government-commissioned research from 2013. Second, most overseas students, like their domestic and EEA peers, are young and healthy, and consequently make few demands on NHS services. In fact, even the weighted estimate of their cost per head – that £700 figure – incorporates assumed costs based on the higher birth rates common among women in their early twenties: yet very few overseas students actually give birth while at university. As the report on which the introduction of the surcharge was based admitted, the estimated costs to the NHS of each student reflected ‘a considerable margin of uncertainty’.  The NHS services that young people are more likely to use – emergency services, treatment for certain contagious diseases, family planning services and compulsory mental health treatment – remain free, either because they benefit the general public health and safety, or because access to such care is still deemed to reflect core UK values (and simple human decency). One might therefore wonder: are the students getting any additional services for their money?

Within six months of its implementation, the Health Surcharge brought over £100 million into the Treasury. According to the Home Office at the time, this income ‘contribute[d] to the NHS for the benefit of us all.’ Perhaps this why this charge on international students produced few ripples in public opinion or the media, particularly in today’s atmosphere of constant NHS crisis. The NUS and voices from the education industry certainly deprecated the charge for students, noting that it might harm the sector and make individual students feel unwelcome. Migrants’ rights organisations also criticized the charges, though their emphasis was almost entirely on the potentially negative impacts it could have for international workers and their families, and for the British communities whose own entitlement to NHS services might be questioned in the rush to ensure compliance with the new rules. Not only were most long-stay migrants already likely to be healthy young taxpayers, and thus net contributors to the NHS, but as one such body, the Migrants’ Rights Network noted:

“The Home Office advice does not explain how NHS service providers in the UK are going to be able to identify non-EU national patients whose eligibility for treatment will be dependent on payment of the surcharge…a lack of clarity on this issue will give rise to confusion as to who is entitled to treatment on the NHS and who will stand to be refused.”

But there were no backbench rebellions, no street marches, and few if any attention grabbing public protests, even on university campuses.

This muted response is strikingly different from what happened the last time a Conservative government tried to impose costs on university students and other overseas ‘visitors’ (then defined as anyone neither in work nor resident in the UK for at least 3 years) accessing the NHS. When on 12 March 1981, Margaret Thatcher’s Secretary of State announced plans to introduce NHS charges for overseas patients, including students, it provoked uproar. As in 2015, the Joint Council for the Welfare of Immigrants and other similar bodies were highly critical, as were organizations dedicated to improving what were then called ‘race relations’.  But in 1981, many other voices were also raised in protest. The Trade Unions Council [TUC] rejected on behalf of the combined NHS unions the very idea that NHS staff should operate identity checks before providing necessary care. The Lecturers’ Union (roughly equivalent to UCU) ‘condemned’ the policy outright as it applied to students and ‘deplored’ its probable effects on ‘race relations’. The Government’s proposals, they proclaimed, ‘would be seriously detrimental’ and it was ‘iniquitous’ for any government to push students into the unscrupulous hands of private insurers who already discriminated against the disabled and, by excluding pregnancy from cover, women. The National Union of Students vigorously protested a policy which would generate NHS ‘apartheid’ and many organizations pointed out the bitter irony that the NHS depended heavily on the labour of overseas student nurses and trainee doctors – but might be forced to charge them for the very care that they provided for free to others, at least until they met certain residency requirements. In fact, protest was so widespread and so vigorous – and so much attention was drawn to the uncertainty both of figures about the costs and benefits of the policy, and to the possibility and effects of enforcement – that the Government was forced to back down.

Like today, the years leading up to Thatcher’s 1981 proposals were marked by economic recession and corresponding austerity, civic and labour unrest (including in the NHS), major concerns about a rising tide of xenophobia and racism, and a widespread sense that the NHS was in crisis, and perhaps at the verge of disaster. Public and political concern about ‘medical tourism’ and the unfair exploitation of the NHS was also widespread and sometimes outspoken. So why did the 1981 proposals fail, while 2015’s ‘surcharge’ passed into law without a hitch? In part, the Coalition Government avoided some of the most deadly pitfalls of the earlier policy: in particular, they outsourced the ugly task of extracting payment by building the ‘health charge’ into the already expensive process of gaining legal permission to enter the country as a student. They also exempted students already in the country, reducing the number of campus voices who would be directly affected by the new policy. Finally, unlike Thatcher’s government, they also offered no model for how the policy might be enforced within the UK. Rather than charging individuals as they incurred NHS costs, the ‘Health Surcharge’ relies on the collection of an (admittedly regressive) fixed universal charge abroad. It does not (yet) require UK health staff to perform identity checks or to assume associated administrative and ethical burdens, and thus did not raise hackles in the NHS itself.

But perhaps too the Coalition relied on us, the anxious and austerity-conscious electorate, to passively accept a charge that would affect none of ‘us’. Are we more ready than in the past to  be convinced by even the sketchiest anecdotal evidence of ‘foreigners’ abusing the NHS? Maybe years of erosion in support for free education — years in which we have heard much about the ‘graduate premuim’ and little about its sharp variations across universities, ethnic groups and fields of study — have made us disinclined in any case to trouble ourselves about students. After all, what is an additional £150 pounds per visa year for young people already willing to assume costs of tens of thousands of pounds a year in tuition alone? And maybe too ‘Thatcher’s children’ (and ‘grandchildren’, the students of today) see access to the NHS with different eyes, as a privilege of citizenship, or a taxpayer’s perquisite, not an outward sign of a national commitment to equity or the human right to health. Nye Bevan, challenged in 1949 to justify visitors’ free access to the new NHS, responded that access to medical care should be seen as part of the ‘normal hospitality’ of a civilized nation. Can we still be proud and confident in our own norms of hospitality, or indeed, in our commitment to that egalitarian post-war vision?

Art Trails and Charity Auctions

An auction in Dundee this evening raised £883,000 for charity. Over the summer the Oor Wullie’s Bucket Trail had seen 55 statues of the iconic Sunday Post comic strip character on display all over the city (as pictured above). The statues were auctioned off to raise money for the ARCHIE Foundation’s charity appeal to support a new theatre suite at the Tayside Children’s Hospital.

In just a few years it’s become surprisingly normal to see these public art trails around Britain. The script is always more-or-less the same. A big fuss is made as a huge number of roughly person-sized statues go up all over local landmarks, shopping areas and in well-known public buildings. Each one is from the same mould, but has been painted by a different (usually local) artist. Families pose for photos as they try to find them all. Then, after a few months, they’re auctioned off to raise money for charity.

We may have gotten quickly used to seeing all these statues, but where did they come from?

Surprisingly enough, the answer is Switzerland (via Chicago).

In 1986 Zurich became home to painted statues of lions, the city’s symbol. Twelve years later this was the inspiration behind artistic director Walter Knapp’s ‘Land in Sicht’ public art exhibition of life-sized painted fibreglass cows, which were auctioned off for charity. The next year the idea was mimicked by a Chicago businessman for the ‘cows on parade’ exhibition, which has since been taken to 79 cities around the world, from Sydney to Istanbul and Rio de Janeiro to Shanghai, with local artists painting the statues and the auctions raising money for local charities. These public art trails have mostly been very popular, despite the occasional controversy. Such as when David Lynch’s gruesome Eat My Fear cow design was rejected for the New York exhibition, or when the Militant Graffiti Artists of Stockholm kidnapped one of the fibre-glass cows in protest at their corporate sponsorship. “Advertisements can never be art”, they declared as they threatened to decapitate the cow unless there was a public statement that they were “non-art”. No such statement was forthcoming. The fibre-glass cow was decapitated.

Although the cows soon arrived in London, Manchester and on the Isle of Wight, it took a decade for a British spin on the idea to come about. Liverpool’s popular Superlambanana – Taro Chiezo’s 17 foot high yellow statue of a lamb with a banana for a tail, which had appeared in the city’s Albert Docks in 1998 – became the model for 124 two metre high mini-Superlambananas around the city. This Go Superlambanas! exhibition was part of the City of Culture programme in 2008, while the statues were auctioned to raise money for the Lord Mayor’s Charity.

'Big Hoot' (2105) photograph taken by George Gosling

shaun-in-the-cityThis became the model for a new wave of public art trails in towns and cities around the UK, often run by the same Wild in Art company behind Go Superlambanas! The first of these tended to raise money for arts and environmental charities, as with Wow! Gorillas in Bristol in 2011, but since there have been a huge range of different themes and causes. There were barons in Salisbury for the Trussell Trust, lions in Bath for a young carers charity, dragons in Newport for a vulnerable young people’s charity, and toads in Hull for environmental projects.

Children’s charities and particularly children’s hospitals, however, have become a common choice. This is due in part to two art trails in Bristol for the Wallace and Gromit Appeal for the Bristol Children’s Hospital – with statues of both 80 Gromit and 120 of Shaun the Sheep (pictured right). The Gromit Unleashed auction in 2013 raised £2.3million and 2015’s Shaun in the City auction a further £1.1million, with the sale of merchandise and spin-off events as far afield as Hong Kong bringing in more than £4.5million and counting. Beyond Bristol, children’s hospitals had received the funds raised from the auction of Dolphins in Aberdeen two years ago, of Birmingham’s Big Hoot owls (pictured above) a year ago, and of the Oor Wullies in Dundee this year; and it’s set to continue with bears in Birmingham next year.

For all the visibility of its incredibly successful branding, there are times when the NHS is hidden. And, despite its popularity, the NHS remains firmly in the small print of these charity art trails and auctions. To some extent, the charity in general is kept distinctly backstage. While entertaining community events have raised money for local hospitals and supporting charities throughout the history of the NHS, it wouldn’t be entirely unfair to say these are part of a new generation of public activities putting the fun back into fundraising. But the NHS is one step again behind the children’s hospital as the focal point of the charity auction.

And this speaks to a thorny issue running through the NHS’s history. Namely, that it can be a cash-strapped beloved national institution, a rallying cry for popular sentiment, and yet still seen as an improper recipient of charitable support. Giving money is  a way of showing support, but at the same time an abandonment of perhaps the most important founding principle of the NHS: that paying for the health services we collectively require is the responsibility of the government. It may be deeply popular and going through some tough times, but in terms of where we might want to send our cash, the NHS will always be a far more complex good cause than sick children.


Oor Wullies (2016) photos kindly donated by Dave Morris, Shaun in the City (2015) by Jennie Maggs, Big Hoot (2015) by George Gosling.

A Cultural History of Organ Donation Week 2016

The funniest joke at the Edinburgh Fringe festival this year, as chosen by a panel of critics for Dave TV channel, was, ‘My dad suggested I register for a donor card, he’s a man after my own heart’ (told by Masai Graham). This week, from 5th–11th September, is Organ Donation Week, an annual drive organised by NHS Blood and Transplant to promote the lifesaving potential of organ donation.  Whilst the jokes of the Fringe and the NHS’s campaigns may not initially appear to have much in common, cultural representations –in comedy, novels, newspapers, and television – have played an important role in reflecting and shaping public debates around the medical, moral, legal and personal implications of organ donation.

Organ donation has a long history.  Whilst there are accounts of skin transplantation dating back as early as the second century, transplants of other organs were not documented until the early twentieth century, alongside improvements in blood transfusions.  Through time, and particularly from the 1940s, surgeons developed their understanding of why certain organs were rejected, and developed immunosuppressive drugs to prevent this.  The NHS’s website writes that the organisation has been ‘at the forefront’ of transplant technology since its own inception in 1948, with the first NHS kidney transplant in 1960, and the first NHS heart and liver transplants in 1968.  The NHS established its first organ donor card, initially just for kidneys, in 1971, and the national organ donor database was created in 1994.  In 2016, we continue to see medical innovation in transplant surgery (for example as surgeons transplant organs between donors and recipients who are HIV-positive).  We also see controversial cases of medical waste, with donor organs in America sometimes thrown away due to an inefficient donor matching system, or weekend under-staffing.

As organ donation becOrgan donorame more common from the 1980s and 1990s, newspapers and factual television programmes paid attention.  In 1985, the BBC consumer programme That’s Life!, presented by Esther Rantzen, appealed for a donor liver for the sick child Benjamin Hardwick.  A liver was donated, and Ben became the youngest liver transplant patient.  The programme also raised £150,000 from viewers and, contemporary newspapers speculated, contributed to a cultural shift empowering parents and clinicians to discuss paediatric organ transplantation.  Echoing this line of thought, in 2014 Matthew Whittaker, who received a liver transplant in 1984 aged 10, told the Daily Mail that ‘I’m 41, but my liver is just turning 30. . . and it’s all thanks to Esther’.

The close relationship between media and medicine was criticised at the time in the Guardian, arguing that journalists had become ‘recruitment officials for organ donors’, and should return to their role as ‘devil’s advocate[s]’, analysing medical research findings and government health policy.  Some newspaper coverage did operate in this critical manner, however, for example investigative journalism exposing an organ trade between Britain and less affluent nations in the 1980s and 1990s.  In one distributing example of this practice, in 1994 The Sunday Times reported that people from Bombay and Madras were selling their organs to British patients for as little as £200, making the ‘middlemen’ organising these deals up to £12,000 per operation.

Films, novels, and television programmes have also invited the public to think about the ethical, legal and personal implications of organ donation.  The film Return to Me (2000) raises issues about identity, emotion, and transplantation, as a man falls in love with a woman who received the heart of his deceased wife.  Similar debates were raised by media coverage around Jeni Stephien in August 2016, who was walked down the aisle by a man who had had her father’s heart transplanted years before, and told assembled media that, ‘It was just like having my dad here, and better’.  Debates about informed consent, and emotional repercussions for donors’ relatives, were also played out in the Mills & Boon novel On Wings of Love (2013), where a transplant nurse falls in love with a grieving widower.  In the American film John Q (2002), a desperate man with inadequate health insurance holds clinicians hostage in a hospital, forcing them to give his son a heart transplant.  This raises questions about the responsibilities of the state in relation to organ transplantation – also discussed in Britain in relation to immuno-suppressive drugs, which recipients of organ transplants currently pay for themselves.

These fictional representations likely invited reflection amongst viewers.  Television producers have also explicitly sought to engender such debate.  In 2005, a Casualty/Holby City crossover special asked viewers to vote to determine the outcome of an organ donation-related storyline.  98,800 viewers called, with 65 per cent voting that a heart donation should be received by Lucy, a young cystic fibrosis patient, over Tony, an older widower.  Demonstrating an entwinement between fact and fiction, the programme also featured an informative section presented by Robert Winston explaining the guidelines governing organ donation.

Cultural representations of transplants can encourage us to think through our positions in relation to organ donation, and to discuss these with friends and family.  A study of 1993 also found that when transplants were featured in newspapers and on television, this made it easier for intensive care professionals to raise the subject of organ donation with grieving relatives.  Cultural representations of transplants can also have a negative effect on discussion, however.  In 2013 the NHS Blood and Transplant group criticised the portrayal of organ donation in an episode of Holby City as ‘inexcusable and reckless’, for representing clinicians treating grieving relatives with ‘callous disregard’.  Demonstrating the real effect of television, the Blood and Transplant group also stated they had been contacted by many people who wanted to be removed from the Organ Donor Register, as a direct result of this programme.

Newspaper articles, television programmes, even junky American films and Mills & Boon books, have all shaped how and when we think and speak about organ donation, by framing and highlighting issues such as consent, emotion, and bodily autonomy in particular ways.  Please do let us know if you see any examples of this sort of thing during Organ Donation Week and beyond.