The government’s latest budget announcement, opening NHS land to private investors to build and operate clinical services “in support of” the health service, has been presented as innovation, partnership, and pragmatic solutions to chronic capacity issues.
But for anyone who has followed the past three decades of health policy, the proposal feels far less novel than ministers would like to suggest. Strip away the modern gloss and the rhetoric of efficiency, and this looks suspiciously like the resurrection of an old Conservative favourite: the Private Finance Initiative (PFI), albeit under a different name.
PFI was once sold as a clever financial tool that allowed new hospitals to be built without immediate public capital.
In reality, it saddled the NHS with decades-long repayment obligations, eye-watering interest rates, and inflexible contracts that have cost the public far more than traditional public borrowing ever would have.
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Many of today’s hospital trusts are still grappling with those legacy costs, diverting money away from staff recruitment, equipment upgrades, and patient care.
The new model proposed in the budget stops short of identical long-term financing structures, but it echoes PFI’s defining logic: transfer public assets or control to private interests on the promise of unlocking capacity and efficiency.
Allowing private investors to build clinical facilities on NHS land may create the illusion of partnership, yet it risks repeating PFI’s core mistake, assuming that private ownership automatically generates public benefit.
The government argues that this approach will speed up the construction of diagnostic hubs, surgical centres, and outpatient premises, relieved of the constraints of public capital budgets.
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But the critical question remains: at what long-term cost, and to whom? If these facilities are ultimately run by private companies, charging the NHS per scan, per bed day, or per procedure, taxpayers may find themselves paying premium rates for activity delivered on land that they already own.
Furthermore, embedding private providers physically within the NHS estate raises fundamental questions about service integration, patient equity, and workforce allocation.
Will private centres given access to NHS plots also receive priority access to NHS clinicians? Will patients be funnelled into privately run ‘NHS-branded’ clinics that ultimately divert resources away from the public system?
If history is any guide, once private operators are embedded in critical pathways, the balance of power shifts and the NHS becomes a price-taker, not a price-setter.
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Supporters of the plan insist this is not PFI, because financing structures differ and ownership of the land itself remains public. This is a semantic comfort blanket.
The spirit of the policy - leveraging NHS assets to entice private capital under the promise of public gain - is entirely consistent with PFI’s ideological DNA. Rebranding it does not change the fact that we are once again outsourcing system capacity rather than investing in sustainable public provision.
The NHS needs capital investment, not clever accounting. It needs long-term staff planning, not fragmented service delivery. And it needs political courage to fund the health service properly, not a new generation of private deals dressed up as innovation.
Calling this policy anything other than PFI-lite is merely an attempt to rewrite a history we should have learned from, not repeat.
Nana Ofori-Atta is the managing editor clinical and custom content at C+D.