6. Could you explain what you understand by risk pooling and whether its use by the private sector to deliver services puts it at risk?
I don't understand this question. The goal of the NHS is universal coverage through integration and risk pooling. The creation of a separate funding stream in the revenue budget to pay for capital or PFI costs is a new cost pressure and creates a new pressure especially when the costs are devolved to small units and areas. The PFI charge, for example, is ring-fenced and also index-linked to RPI; it must be paid before any clinical costs are met. A trust could find its income reduced and, as a result, the charge takes a higher share, thereby creating a pressure on remaining services. This is well illustrated in the work of Hellowell and Pollock on the difference between trusts capital costs and the mismatch between income to cover the costs. The lack of integration and ability to control that portion of costs is and will continue to be a serious problem, especially during any downturn in public expenditure. Reduction in available revenue will simply drive more service cuts, as demonstrated above. For example, whereas the average cost of capital under the capital charging system was 6-8% of income on average, monitor has set a ceiling of up to 15%-almost double the previous figure.