NHS 10-Year Plan: The Corporate Capture Continues
Esther Giles, SHA Treasurer
Introduction
There are many aspects of the NHS 10-Year Plan (The NHS10YP) to consider. Here, we will focus on the capital investment needed in primary and community care- and the NHS10YP proposal to adopt a “Public Private Partnership” (PPP) approach to provide infrastructure for primary care. We draw on work we have done in the SHA regarding NHS structure and privatisation, and primary care services.
The Real Economy
According to the post-WWII political philosophy of the welfare state, it is the Government’s job to ensure that people have the essential public services they need-including housing, health and social care, education, water, energy and a transport infrastructure.
Whereas the private businesses formerly in charge of these areas were limited in their social role by their need to make profit, the government’s actual limits are set only by its own goals, by the real resources available in the economy – the labour, skills, energy and materials it can bring to use – and by managing any inflationary pressures that might arise should spending exceed those real capacities.
The Treasury Rules that Constrain Us
Rooted in the anti-welfare-state philosophy that shaped governments from the mid-1970s, associated with Margaret Thatcher, the 2024 fiscal rules include the investment rule– “to reduce public debt”- defined as public sector net financial liabilities (PSNFL) as a share of the economy. This is why public sector capital investment is constrained as it is – despite the clear need for infrastructure investment. Spending on public sector capital formation less depreciation (net fixed capital formation) is presently only 1%– whereas overall capital investment in the economy is 15-20% of GDP.
THE GOVERNMENT DEBT TARGET (PSNFL) IS A POLITICAL CHOICE AND SELF IMPOSED. IT CAN AND SHOULD BE CHALLENGED.
If we have the real resources to build infrastructure, we don’t need private capital to do it. In fact, we can do what private capital cannot.
10-Year Infrastructure Strategy June 2025
In June 2025 the Government published its 10-year Infrastructure Strategy.This announced plans to sign more partnerships with the private sector for the delivery of UK public services- including health and education- despite the criticism and failure of the Blair Government PFI schemes. In the strategy it says it wants to “evolve our infrastructure finance models and will consider the use of Public Private Partnerships (PPP) in projects and sectors where there is a revenue stream, appropriate risk-transfer can be achieved, and value for money for taxpayers can be secured.” (our bold).
In line with this intention, the Department for Health and Social Care (DHSC) and the National Infrastructure and Service Transformation Authority (NISTA) have published a preliminary market engagement notice for what they call “Project Wings” and which concerns “certain types of primary and community health infrastructure projects”. The total value of the project is estimated at £1.2bn (inc VAT), running for 30 years from June 2027. Investors have been invited to design, build and manage up to 200 neighbourhood health centres (NHCs), with contracts for between 25 and 30 years. It is expected that a final decision on the approach will be announced in the Autumn Budget on 26th November.
The Return of PPP/PFI
The 10-year Infrastructure strategy underpins the investment plans in the NHS10YP and the return to PPP.
The context to this is that (from the Infrastructure Strategy):
Capital investment in the NHS has lagged international peers for over a decade, with the UK sitting amongst the lowest in the Organisation for Economic Co-operation and Development (OECD) indicators for capital investment. This has led to a c.£37 billion infrastructure gap, highlighted by the Darzi Report, which has left the NHS with outdated, inefficient, and ill-suited infrastructure.
Despite the very low number of hospital beds in the UK across the OECD (see chart below) shifting patient care out of hospitals and into the community remains one of three core themes of the 10-year health plan.
NHS England has already started work- based on the 10-year infrastructure strategy- on a new model to draw in private finance to pay for health infrastructure, using what its leadership calls an “off-balance sheet capital investment mechanism”. Which means that nothing real changes, but we change the way we measure it to comply with the treasury rules.
In the NHS now, (politically chosen) “capital constraints” together with elective capacity shortfalls and primary care investment backlogs, combine to usher in a new PPP/PFI model.
The NHS Confederation stated in a report released on 8th September 2025:
“off-balance sheet models, which keep the debt off the government’s books, are a political necessity in the current fiscal climate”
This is despite the Conservatives having banned PFI for central government projects in 2018 after the NAO declared them poor value. Hundreds of PFI projects from this period are still mired in legal disputes between government and private investors. Now the Government is saying that any new PPP models would be “drawn up differently to avoid the problems of the PFI era”.
Neighbourhood Health Centres (NHCs)
The proposed NHCs would bring together healthcare and local authority services in a “one-stop shop”. The development of combined premises for primary and community care has happened in only a limited way in the past because of the fragmented nature of the private contractor model in primary care, with primary care premises primarily being provided by general practitioner (GP) private contractors to the NHS. The current contractor model brings with it high risk of market failure and the Royal College of General Practitioners (RCGP) has previously called on the Government to invest £2bn into GP premises, after a survey found that 40% of GP staff think their premises are ‘not fit for purpose’. Furthermore, under the measures in the 2014 5 Year Forward View and its successor, the 2019 Long Term Plan, many practices are now being “bought out” by large corporations such as HCRG (previously Virgin), Centene and Operose.These commercial companies have been gifted opportunities for profit where there is a need for a publicly provided model.
Initiatives for private sector investment in primary care have been attempted before, principally via a type of PPP called LIFTs (local improvement finance trusts) of which there are around 50 and which a Labour health minister at the time compared favourably with Kaiser Permanente in the USA)- but the bureaucracy, the profit motive and margin requirement; problems over the question of ownership- all are problematic, as with PFI projects.
Our View
- The government is constrained only by its own will and the real resources available in the economy. Present Treasury and austerity constraints are a political choice. Capital funding constraints are self imposed by the government and can and must be challenged. Local publicly funded and managed building schemes are likely to be much cheaper and more socially useful than the LIFT/PPP equivalent. We must reverse and avoid private finance use of the NHS. There is no place for profit in healthcare.
- Investment in primary care does not in itself provide a “silver bullet” that will address the UK’s very low number of hospital beds and the marketisation and privatisation of the NHS. The NHS must be restored to a comprehensive, universal service operating in the context of a functioning welfare state.
- The NHS10YP plan fails to acknowledge the role of the market in perpetuating many of the infrastructure problems in primary care- and proposes market solutions supposedly to resolve them.
- The co-location of community and primary care could serve communities well- particularly in the event they can access publicly provided GP care, NHS dental care, and other community services in a single hub connected to a secondary or tertiary healthcare provider.The only purpose of inviting corporations to ‘help’ fund or deliver neighbourhood health centres is to shape them around private sector expansion rather than public need. We are mindful of documented negative financial and health outcomes resulting from private sector involvement in public healthcare restructuring.
- A national NHS salaried contract must be introduced for GPs and Dental Practitioners (DPs) (as supported by Doctors in Unite) as part of a consolidation of publicly provided primary care services and we need to bring an end to Alternative Medical Provider Service (APMS) contracts, which allow private companies to buy up GP contracts. There may continue to be partnerships of professionals who are involved in direct service provision these could include DPs and other healthcare professionals