Managing risk and regulation within new local ‘health economies’: The case of NHS LIFT (Local Improvement Finance Trust)

Abstract

This paper analyses NHS Local Improvement Finance Trust (LIFT), a relatively new policy that shifts UK primary care premises into corporate ownership. LIFT is a more radical version of the Private Finance Initiative (PFI), and may indicate the future direction of neoliberal welfare services. Like PFI, LIFT foregrounds issues of risk and regulation, enabling their reconceptualization. This echoes certain themes present in the sociology of risk, including the idea that the welfare state has created and amplified, rather than managed, risk. Under LIFT, risks are constructed as (a) primarily economic and (b) primarily from the point of view of the large commercial organizations involved. Evidence presented here depicts banks as risk averse, challenging assumptions that private firms display risk-taking behaviour. The prioritization of economic risks is shown to amplify social risks, and to produce threats to social regulation. These threats are amplified by unequal power relationships within these new ‘local health economies.’ It is argued that LIFT is undermining the NHS's social embeddedness in local areas, partly by threatening the position of general practitioners and other small business or community organizations. Ultimately, the model is likely to generate new social and economic risks currently obscured by official discourse around LIFT.

Keywords:

• Privatization
• primary care
• NHS LIFT
• commodification
• PFI
• health

Notes

1 Here I am using PPP to refer to PFI, LIFT, and similar initiatives such as Building Schools for the Future.

2 Obviously simplifying here, as risk is measured by multiplying impact by probability.

3 All NHS organizations were constituted as Trusts by the Conservatives between 1991 – 1995, and this was not repealed by Labour.

4 This structure allows liability to be strictly limited to initial investments in each ‘Fundco’ or project holding company; thus financial difficulty affecting one project will not affect investors' holdings in other projects.

5 Although in the case of LIFT, as the local public sector organizations own a minority shareholding in the FundCos, they would share 20% of the financial gains from such a transaction.

6 I would argue that in practice, the private sector tends to avoid assuming demand risks, certainly in LIFT this is the case.