The private finance initiative. NHS capital expenditure and the private finance initiative-expansion or contraction?

Stakes, positions and logics: An institutional field analysis of cross-border health IT policy

The concepts field and habitus are used widely and variably in institutional theory. The intellectual antecedents are found in the work of the French Sociologist, Pierre Bourdieu. This study presents a field-level analysis of pan-European policy on cross-border health information technology. Using field theory and institutional theory, we situate field as a multi-level concept which extends institutional and organizational levels of analysis. Empirical data is gathered from European policymakers, health professionals and patient advocacy groups on the diffusion of supra-national health information technology across European Member States. Findings reveal four scenarios depicting field tensions, as ideological and practical imperatives of supra-national health information technology policy mis-align with Member State health systems. This study has implications for policy-makers and other stakeholders, who seek to narrow the digital divide across health fields and sub-fields.

Should prospective payments be differentiated for public and private healthcare providers?

The English government has encouraged private providers – known as Independent Sector Treatment Centres (ISTCs) – to treat publicly funded (NHS) patients. All providers are to be remunerated under a prospective payment system that offers a price per case treated, adjusted by the Market Forces Factor (MFF) to reflect geographical variation in specific input costs. This payment system presupposes that any remaining cost differentials between providers result from inefficiencies. However, the validity of this assumption is unclear. This article describes the constraints that could cause public and private provider costs to differ for reasons outside their control. These constraints may be regulatory in nature, such as taxes and performance management regimens, or relate to the production process, such as input costs, the provision of emergency care, and case mix issues. Most of these exogenous cost differentials can be rectified by adjustments either to the regulatory system or to the payment method. However, differences in capital costs appear less tractable and further investigation into possible solutions is warranted.

Contractual design and PPPs for hospitals: lessons for the Portuguese model

Recently the Portuguese Government announced the launching of public-private partnerships (PPPs) to build hospitals with the distinctive feature that infrastructure construction and clinical activities management will be awarded to separate private parties. Also, one of the parties will be in charge of providing soft facilities. We explore alternative configurations of contracts and assess whether the equilibrium allocations attain the first-best solution.

Financing and planning of public and private not-for-profit hospitals in the European Union

While much has been written about health care financing in Europe in recent years, discussion has almost entirely focused on revenue. In contrast, there has been remarkably little written on financing of capital investment in European health care systems. Yet major changes are underway in several countries, in particular involving new forms of public-private partnerships (PPP). At the same time, there is growing recognition of the way in which the inherited structure of the health care delivery system constrains the system's ability to adapt to changing circumstances. This paper reports the results of a survey undertaken among key informants in the member states of the European Union to begin to ascertain existing practices and future plans in relation to hospital planning and financing amongst public and private not-for-profit hospitals. The locus of hospital planning decisions reflect the constitutional framework of the country involved, and thus the emphasis on national or local plans. There has been an expansion of private sector involvement, with four basic models identified: private loans direct to the hospital; private loans to a regional health body; a PPP where the private sector's role is to build, design and operate the non-clinical functions of the hospital; and, finally, a PPP, where the private sector's involvement also includes management of the clinical functions of the hospital. It is too early to say whether these approaches will be more successful than the models they are replacing.

Downsizing of acute inpatient beds associated with private finance initiative: Scotland's case study

OBJECTIVES

To evaluate whether the projected 24% reduction in acute bed numbers in Lothian hospitals, which formed part of the private finance initiative (PFI) plans for the replacement Royal Infirmary of Edinburgh, is being compensated for by improvements in efficiency and greater use of community facilities, and to ascertain whether there is an independent PFI effect by comparing clinical activity and performance in acute specialties in Lothian hospitals with other NHS hospitals in Scotland.

DESIGN

Comparison of projected and actual trends in acute bed capacity and inpatient and day case admissions in the first five years (1995-6 to 2000-1) of Lothian Health Board's integrated healthcare plan. Population study of trends in bed rate, hospital activity, length of stay, and throughput in Lothian hospitals compared with the rest of Scotland from 1990-1 to 2000-1.

MAIN OUTCOME MEASURES

Staffed bed rates, admission rates, mean lengths of stay, occupancy, and throughput in four adult acute specialty groups in 1990-1, 1995-6, and 2000-1.

RESULTS

By 2000-1, rates for inpatient admission in all acute, medical, surgical, and intensive therapy specialties in Lothian hospitals were respectively 20%, 6%, 28%, and 38% below those in the rest of Scotland. Day case rates in all acute and acute surgical specialties were 13% and 33% lower. The proportion of delayed discharges in staffed acute and post-acute NHS beds in Lothian hospitals exceeded the Scottish average (15% and 12% respectively; P<0.001).

CONCLUSION

The planning targets and increase in clinical activity in acute specialties in Lothian hospitals associated with PFI had not been achieved by 2000-1. The effect on clinical activity has been a steeper decline in the number of acute beds and rates of admission in Lothian hospitals compared with the rest of Scotland between 1995-6 and 2000-1.

How the World Trade Organisation is shaping domestic policies in health care

High up on the agenda of the World Trade Organisation (WTO) is the privatisation of education, health, welfare, social housing and transport. The WTO's aim is to extend the free market in the provision of traditional public services. Governments in Europe and the US link the expansion of trade in public services to economic success, and with the backing of powerful medico-pharmaceutical, insurance, and service corporations, the race is on to capture the share of gross domestic product that governments currently spend on public services. They will open domestic European services and domestic markets to global competition by government procurement agreements, dispute-settlement procedures, and the investment rules of global financial institutions. The UK has already set up the necessary mechanisms: the introduction of private-sector accounting rules to public services; the funding of public-sector investment via private-public partnerships or the private finance initiative; and the change to capitation funding streams, which allows the substitution of private for public funds and services. We explain the implications of these changes for European public-health-care systems and the threat they pose to universal coverage, solidarity through risk-pooling, equity, comprehensive care, and democratic accountability.