Intended for healthcare professionals

Views And Reviews Primary Colour

Helen Salisbury: Debts of gratitude

BMJ 2021; 372 doi: (Published 23 February 2021) Cite this as: BMJ 2021;372:n514
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

Sometimes my day is brightened by someone’s gratitude. Even if I barely remember the consultation referred to in a card, clearly it was appreciated by the patient. If I’m thanked in person I often respond, quite truthfully, that I was just doing my job. Conversely, most GPs have experiences of patients for whom they’ve gone the extra mile—with hours spent on long consultations, referrals, and advocacy—and received not gratitude but vocal dissatisfaction and sometimes formal complaints.

As a patient, I too have felt grateful to individual clinicians who have found the right words at the right time, who have been gentle and kind. But should I feel gratitude to the NHS as a whole? I’m certainly grateful to the post-war politicians who had the boldness to dream of a world where healthcare was a right and not dependent on charity (for, as Clement Attlee observed, charity is a cold, grey, loveless thing) and had the vision to create our NHS.

The problem with gratitude is that it can imply that we’ve received something that wasn’t already ours by right. The NHS is funded by our taxes, explicitly to provide care and treatment for everyone in the UK. Those of us who earn enough to pay taxes should render up the money willingly; those who don’t should be secure in the knowledge that they’ll get the care they need. How much tax we each pay, especially in the upper earning brackets, is a matter for debate (leaving aside the issue of Modern Monetary Theory)1: how sensibly, carefully, and transparently our money is spent is a subject currently occupying the news media and the law courts.2 Should there be a role for NHS charities? Are they needed as places through which patients can express their gratitude and “give something back”?

This has been a heated topic locally, including a community newsletter suggesting that residents might wish to donate the “cost” of their vaccine to such charities. More widely, Captain Sir Tom Moore became an inspirational role model for his remarkable fundraising.3 There are concerns that people without much cash may feel a moral obligation to contribute, perhaps even confusing these charities with the NHS itself. But, as our health service is state funded, a more fundamental question is at stake: what purpose are these charities intended to serve?

You might expect charitable funds to be earmarked for optional extras—artwork on wards, treats for staff or patients. However, the website of the umbrella organisation for NHS charities states that in recent years they’ve funded “major capital projects, pioneering research, and medical equipment at our hospitals, helping patients access the best possible care when they need it most.”4 Isn’t this what core NHS funding is meant to do?

We must be careful not to let our gratitude to the people who work so hard in our NHS, and give so much of themselves, obscure the NHS’s founding principles. Above all, let’s celebrate the fact that, back in 1948, we moved beyond the need for charity.