Intended for healthcare professionals

Opinion Christmas 2023: Annual leave

All the trimmings: patient and staff wellbeing should not be left to charitable funding

BMJ 2023; 383 doi: (Published 18 December 2023) Cite this as: BMJ 2023;383:e077982
  1. Ellen Stewart, co-director, Centre for Health Policy, University of Strathclyde,
  2. Rosemary Cresswell, research fellow, University of Strathclyde

We need a wider debate about how charitable funding contributes to the NHS, argue Ellen Stewart and Rosemary Cresswell

Tokens of festive jollity—parties, decorations, and a communal tin of chocolates—pepper UK hospitals in December.1 Health service archives catalogue 75 years of celebrations, along with recurrent negotiations between administrators over whether NHS budgets, charitable donations and funds, or staff and patients themselves should pick up the bill. By providing “non-essential” things the NHS cannot afford, charitable funds often soften the edges of a struggling system. But, in another year where joy among the NHS workforce has been in particularly short supply, we should resist the suggestion that patient and staff welfare are “extra” to core business.

Questions about what is essential in the NHS are neither easy, nor new. In hospitals in the 1950s, charitable funding continued to play an important role in festivities as the new NHS sought to define the boundaries of acceptable exchequer spending. In the early 1950s, for example, records show that Christmas activities were the largest expenditure from the charitable endowment funds in many Welsh hospitals,2 with the Rhymney and Sirhowy Valleys Hospital management committee reporting charitable spending on “Christmas extras, staff entertainments, sports equipment, cinematograph accessories, and film hire.”3

In the early years of the NHS, central government oversight sought to distinguish what was essential from what was “nice to have,” with variable success. In 1946, lord chancellor William Jowitt argued that “those little—dare I call them trimmings?—which make so much difference to the comfort and happiness of patients” should continue to be provided by charitable funding (instead of the exchequer).3 But there was political sensitivity in government that public funding for the NHS might appear inadequate.3 In 1949, after discrepancies in the provision of books, sanitary products, and even toilet paper between hospitals, Ministry of Health official John Pater stated that the new NHS must fund “all the essential needs of mind and body” for patients.4 Defining such essentials proved thorny, however: in 1951, the Department of Health for Scotland wrote to regional hospital boards clarifying that NHS funding could pay for a Christmas dinner for staff (but not a party) and a Christmas gift for child patients (but not adults).5

Decades later, boozy staff parties won’t be charitably or NHS funded. But charitable funding still pays for many things that are deemed to be non-essential for NHS staff and patients,6 including celebrations of a broader range of religious holidays.7 Since the height of the covid-19 pandemic, staff wellbeing initiatives—counselling, helplines, and “wellbeing zones” in hospitals for breaks—have been a particular focus of NHS charity spending. Yet as staff morale plummets8 and picket lines form,9 there has been little policy acknowledgment that charity funding means the availability of such support varies across hospitals—or indeed that heightened demand for them is driven by broader underinvestment.10

As William Jowitt recognised, describing initiatives that make a difference—whether to staff welfare or patient comfort—as “trimmings” risks implying triviality. Research on free refreshments for staff in last year’s Christmas BMJ showed how simple resource allocation decisions are deeply intertwined with morale, retention, and recruitment.11 While charitable contributions have provided moments of comfort and joy in NHS hospitals for decades, relying on local decisions about essentials and trimmings masks a shift towards a more frugal approach to healthcare provision. In a public system like the NHS, decisions about what is essential, and what is simply nice to have, require an open debate including patients, staff, and the wider public. As staff distribute charitably funded gifts of festive cheer to patients this Christmas, we need more transparent and inclusive conversations about what is essential, and how to fund the NHS to pay for them.


  • Competing interests: Both authors’ time is funded by a Wellcome Trust Collaborative Award in Humanities and Social Science on charity and voluntarism in the NHS since 1948 [219901/C/19/Z] and [219901/D/19/Z]. ES also receives research funding from the UK Prevention Research Partnership.

  • Provenance and peer review: Commissioned; not externally peer reviewed.