Hospitals Overall 1 year mortality rate Overall 3 year mortality rate NNUH 103.5 103.55 Addenbrooks Hospital 79.3 78.82 National average 100.0 100.00 Source Dr Foster Intelligence. By 2011/12 NNUH had improved its performance, as shown below, but not proportionately against the Addenbrooks Hospital (listed here as Cambridge). Other local non-teaching hospitals are also included for comparison. Source Dr Foster Intelligence. Between 2002 and 2006 the hospital saw 65 patients die from MRSA, (making it one of the ten worst hospitals in the United Kingdom in terms of deaths from this infection). Although this situation has been recovered to significant degree, Monitor (the independent regulator of Foundation Trusts) noted that NNUH “had nevertheless missed some of its quarterly targets for overall infection control rates for 2012.” Source, Monitor and Dr Foster Intelligence. Again there would not appear to be any co-relation of results to the adopted PFI model. 13. Lessons learned The lessons learned relate to the following: ? The impact of PFI on hospital planning processes; ? Adaptability in meeting future changes in demand and patient need; ? Value for money decision-making; ? Affordability and the (operating) cost implications of PFI; ? Effect of PFI on clinical and operational service; ? Openness and transparency and public reaction to the PFI model; ? Competence and capacity to implement PFI projects; ? The future of PFI in the healthcare sector; 13.1. PFI and Hospital Planning From the moment the Department of Health signalled PFI as the ‘only practical solution’ to financing the new hospital, the primary consideration was agreeing a minimum capacity model (bed configuration) that allowed the NNUH to afford the higher level of (usage) charges associated with PFI. This strategy of compliance with a PFI process driven outcome overwhelmed any consideration of long-range strategic visioning and innovative concept development. The only tangible benefit seems to be that PFI enabled the accelerated provision of the new hospital. Health and Economics Analysis for an Evaluation of the Public Private Partnerships in Health Care Delivery across EU 53 Recent pan-European studies demonstrate the benefits of basing new hospital planning on newer service concepts that reflect continuous changes in models of care, changing clinical demand (associated with ageing and chronic illness) and new principles of patient flow within and across the local healthcare sector. The key message is that any PPP solution should support and maintain the integrity of the strategic vision and facilitate a cost effective capital solution – as opposed to dominating and compromising these needs as the NNUH PFI model seems to have done. 13.2. Adaptability in meeting future changes in demand and patient need The output specification required by NNUH related primarily to capacity (bed provision) – the design was expected to adapt to future increases in demand. Within a few years of opening this flexibility had been exhausted. Furthermore the design was required to comply with central (Department of Health) standard ‘building guidelines’ relating to spatial allocation and cost ratios. The result; a building with a ‘modern environment’ but wholly conventional in concept – territorial based specialty departments, conventional ward configuration (very low ratios of single rooms, 30%, compared with 100% in most new European hospitals) and little attention paid to the need for future functional change. The rapidity of change in clinical technologies, new models of care and changing needs of patients will place the hospital under extreme pressure as the design concept – locked in place with a rigid contract structure – seems ill equipped to respond. The lesson: future hospital planning and design must take into account and provide for the changing nature of healthcare delivery and the anticipated shift of more care into local community settings. Under PFI the PFI company has no contractual accountability to share and manage the risk of changing capacity and functional need. This has been identified as one of the key shortcomings of the PFI model. 13.3. Value for money decision-making The lack of transparency and liberal application of adjustment figures when comparing the PFI model with a hypothetical (public sector comparator) model has undermined confidence in the PFI process. Subsequent Parliamentary committees have called into question the value for money basis of PFI projects (see PFI generic study). 13.4. The (operating) cost implications of PFI The PFI usage charge to NNUH represents around 13% of its total annual operating budget, £18 million per annum at (2007/8 prices). This is fixed, subject to an inflation escalator. It is in effect a first charge on the hospital’s operating budget irrespective of patient volumes (and associated income). In common with almost all English NHS hospitals NNUH now faces year on year efficiency targets, and a local reform plan that aims to shift more hospital care into community settings. The hospital has virtually no room for manoeuvre. Although it is difficult to prove cause and effect of the slip into deficit by NNUH, circumstantial evidence suggests that the high cost and inflexibility of the PFI model is a major contributory factor as the call for ever increasing efficiency savings in the NH ratchets up. The lesson, unless the PFI deal is in some way related to managing the risk of change – an open flexible contract – PFI hospitals will be exposed to significant financial stress if facing future loss of income (volume or tariff reductions) or the need to meet (cash releasing) efficiency targets. On a final authoritative note: the Audit Commission (2006) has identified an association between large new building projects (almost all PFI schemes) and financial deficits in the NHS.
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Hospitals Overall 1 year mortality rate Overall 3 year mortality rate NNUH 103.5 103.55 Addenbrooks.