How private finance is moving primary care into corporate ownership.

A central aim in establishing the NHS was to integrate primary care and health and social services in health centres. But this aim was compromised by the absence of public capital and the reluctance of the Treasury to buy out practice premises owned by general practitioners. Although there was some grant funding for health and local authority owned health centres, by 1974 only 15% of general practitioners operated out of these. General practitioner owned practice premises remained the dominant model from 1966 until 1989, financed by government loans and funded from NHS revenue under the rental reimbursement schemes. The privatisation of the government loan body in 1989 saw a switch to private finance and the entry of commercial companies and for-profit corporations. The amount of capital that can be raised by the private sector for new investment in the NHS is unrestricted. However, these debts have to be repaid through NHS funds or user charges. The renewed impetus for integrated services in the 1997 white paper, The New NHS, means that more sophisticated buildings are required to accommodate advanced clinical technology and information systems. The complex financing and funding arrangements, combined with demographic factors, makes it likely that as general practitioners opt for a salaried service, the trend to for-profit corporations owning and buying out practice premises will accelerate. Currently, primary care services are provided by 29 987 general practitioners in 9000 main surgeries and 2500 branch surgeries. The most recent survey of ownership carried out by the NHS Executive’s valuation office in 1995-6 showed that 63% of practice premises were owned by general practitioners, 16% were owned by the NHS, and 21% were rented from the private sector. In its first capital investment strategy for the NHS, the Department of Health proposed a “national target of improving 1000 GP premises over the next 3 years [by] replicating the success of big hospitals in non-acute settings and to explore the scope for PFI [Private Finance Initiative] type solutions in primary care.” Recent estimates suggest that about £10bn needs to be invested in primary care over the next decade. Investment has started and is accelerating under the government’s public-private partnerships initiative. Although loans for practice premises are now increasingly from the commercial sector (see background paper on the BMJ’s website), few data are collected centrally on the different types of publicprivate partnerships in primary care, their financing, and the implications for NHS expenditure. This article describes the new forms of ownership that are emerging in NHS primary care services.