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The case against

Peter Dixon describes his colleague professor Allyson Pollock as having 鈥渁 very strong stance on the PFI鈥�, which is a bit like saying that the Pope takes an interest in religious matters, or that wild bears occasionally toilet al fresco. In fact, Pollock does not regard the PFI as a questionable procurement route; she sees it as the exchange of treasured birthrights for a mess of pottage.

Pollock chairs the Public Health Policy Unit at University College London, a platform that has enabled her to become the academic wing of the anti-PFI movement. As such she is a thorn in the side of the government and on-message Labour MPs, and a rallying point for an increasing number of dissident chief executives, union leaders and voters.

Pollock puts her case with aplomb. 鈥淭he NHS was and is the jewel in the crown of the welfare state, but it is in danger. We are now in a completely new era, not of downsizing through lack of investment but of privatisation and markets. The consequences are going to be catastrophic: for the public, for patients and for services. We are going to go back to a pre-1948 situation, or rather forward to a US-type health system where, increasingly, healthcare is limited and there will increasingly be a lottery for care.鈥�

That鈥檚 the big picture. Her criticisms of the details of the PFI process are equally trenchant: she cites in particular the 鈥渞evolving door鈥� through which senior health officials depart, only to return shortly afterwards transmogrified into private consultants who put their insider knowledge at the service of PFI contractors, and thereby blur the boundary between public and private.

In NHS plc, the book she wrote with her UCL team, she notes: 鈥淐oncerned NHS bodies (such as the British Medical Association) who saw career patterns such as these as involving conflicts of interest were increasingly dismissed as naive or self-interested. Public servants who were unwilling or unable to go along with the trend had by then [2003] been largely squeezed out through retirement, restructuring and retrenchment.鈥�

As well as being bad public policy, she argues that the PFI is bad business: the state ends up paying more for its finance than it would if it raised funds on the bond market. In addition she makes the familiar point that PFI consortiums have to make a profit and pay for all those consultants, and she accuses the government of manipulating the evidence provided by public sector comparators to conceal the wastefulness of this.

None of this is exclusive Pollock territory.

The Centre for Policy Studies, a right-of-centre think tank, recently published a booklet called Reforming the PFI that rehearses the same criticisms, although it wants to amend rather than eliminate the initiative.

Where Pollock differs from the general run of critics is her knowledge of the facts on the ward. She points out that the bill for PFI deals has to be paid partly from operating revenues. Given the fact that the government has earmarked 拢110bn for PFIs over the next 25 years, this has obvious implications. She points out that administrators are constantly scraping around for money, and many have created retail outlets in hospitals, introduced charges for car parking, attached pay-to-view televisions to beds, skimped on canteen facilities for staff and created 鈥減ay beds鈥�.

She also suggests that administrators have been forced to pennypinch over ancillary services, such as catering and cleaning. She says this has contributed to the rise in deaths caused by the MRSA superbug. According to the Office of National Statistics, the death rate has climbed from 210 in 1993 to 5309 in 2002.

Another line of attack is the effect of the PFI on the NHS鈥� overall capacity. PFI hospitals, she says, pay more for their beds and therefore contain fewer of them than the facilities they replace. She quotes testimony from a patient at the Royal Infirmary Edinburgh, a PFI scheme completed in 2003. This was built at the cost of 拢250m and a 24% cut in bed numbers.

We are going back to a pre-1948 situation, or rather to a US-type system where healthcare is a lottery

鈥淭he beds never get cold,鈥� said the patient.

鈥淎t times we are shuffled like cards in a pack. Yesterday two new patients sat in the ward day room from 10.30am to 5.30pm waiting for beds to be vacated. Last week an 88-year-old and I were whisked along miles of cold draughty corridors in three lifts to spend the night in a gynaecology ward.鈥�

Then there are her objections to the way the health service has been force-fed the government鈥檚 financial medicine. A section in NHS plc entitled 鈥淥vercoming opposition鈥�, lists these, in no particular order, as: polluting or dismissing scientific evidence (partly by No 10鈥檚 rapid rebuttal team), discrediting and intimidating critics, promoting the American way, promoting the 鈥淐ontinental system鈥� (Pollock is not an admirer of France鈥檚 social insurance-based healthcare), aggravating stress and gagging staff.

Pollock takes more than an academic interest in the PFI. She trained in medicine in Scotland and has worked at hospitals in Edinburgh and Leeds. Her own views on Britain鈥檚 health service are based on the founding principles of the welfare state: the freedom from want and fear envisaged by Sir William Beveridge, the father of the NHS, and Aneurin Bevan, the secretary of state for health and housing who said the noise of a dropped bedpan ought to 鈥渞everberate throughout Whitehall鈥�.

She shares Bevan鈥檚 faith in the value and effectiveness of planning. For Pollock, as for Bevan, a national system is crucial to establishing a database of clinical need, which was, and is, the precondition for the effective distribution of resources. Hence her visceral distaste for foundation hospitals, which will be permitted to operate as almost stand-alone institutions, and specialised diagnosis and treatment centres for ailments such as hernias and cataracts.

Whatever next?
She has her own views on why foundation hospitals and specialised treatment centres are so popular with the government: it is part and parcel of a 鈥減aradigm shift鈥� away from a needs-based national system to a decentralised one driven by market priorities that cherrypick lucrative patients and treatments.

What does the future look like for Pollock and her team? After seven years on the front line of the battle over PFI, they have some scars to show as well as victories. She has clearly had one or two run-ins with senior civil servants, and one PFI mandarin contacted by 好色先生TV remarked, tersely, that Pollock had a 鈥渟elective memory鈥� of one skirmish.

One of her old adversaries on the health select committee is Julia Drown, the Labour MP for Swindon South, who is an accountant with public sector experience. Drown is convinced that the PFI has a future, and argues that it encourages consortiums to take clients more seriously because of the long-term relationship involved. In the old days, says Drown, construction companies simply 鈥済rabbed the cheque and ran away鈥�. Now it is in their interest to get it right first time as they must handle maintenance. She also dismisses Pollock鈥檚 concerns about covert privatisation, arguing that the government has shown its commitment to the NHS by increasing its funding of healthcare.

Pollock takes a bleaker view, citing the pressure exerted by the World Trade Organisation to open the healthcare market to private firms. But whatever the merits of Drown鈥檚 arguments it is by no means clear that PFI itself is here to stay: support, beyond the ranks of the government and interested parties in the industry, seems fairly muted.

And despite the amount of time the PFI has had to bed down, it still hits the headlines for the wrong reasons. Up to now, no hospital has emulated Tube Lines by buying vital bits of kit from eBay. However, with news that Bradford Teaching Hospital, one of the torchbearers for foundations, is heading for an 拢11m deficit, now may be a good time to flog that old magnetic resonance imager.