Sustainability from the perspective of the ARSLVT and the SNS are also been considered acceptable by the MoH authorities, though comparisons are not yet useful due to the short operating period. In terms of risk transfer and risk management, the MoH has effectively transferred clinical risk, management risk including those risks related to staffing costs and levels, infrastructure construction and operating risk, production risk relative to the annual ceilings, interest rate risk and financing risks, as with the other similar projects. The major service impact factors of the PPP are quantified in the 150 indicators provided monthly to the ARSLVT, some of which will be published regularly in the coming months. For example, the one-month snapshot below shows that s of November 2012 Loures had already achieved a bed occupancy rate was a record 73,21%, 71,76% of surgeries were ambulatory, though 5-day readmission rates were relatively high 2,24%. Thus far, there is no report of detrimental impact on services, unplanned changes in bed numbers or staffing levels. The Loures hospital has gotten off to a good start, though no financials are available yet. If it continues in this level it should make a positive contribution to the health policy objectives of increasing access, efficiency and sustainability for the SNS. 8. Lessons Learned Some of the specific lessons learned from the Loures PPP hospital can be ordered according to the basic PPP project phases, preparation, execution and monitoring. Preparation involved a costly lesson with the cancellation of Loures I but the procurement of the repeat Loures II was executed smoothly. Project selection was guided by general considerations of the population needs and the dimension and was adjusted downward by over 20% to allow for another hospital which has since been suspended. This is a not-unusual planning problem for large infrastructure given the long lead times. Altogether, the Loures hospital took about eight years from launch of the first tender to financial close of the second tender in December 2009, in vastly different market conditions. The PSC public sector comparator developed with inputs from other SNS units, is essential and it can serve to effectively cap bid prices. Loures was able to secure financing on good terms, 27-year maturity, despite the on-set of the financial crisis, in part because it had secured firm funding commitments from its creditors, including one which is part of the same economic group as the lead shareholder Espirito Santo Saúde. 9. Sources of Data Hospital Beatriz Ângelo presentation, Nov-2012; Hospital Beatriz Angelo http://www.hbeatrizangelo.pt/fotos/clipping/hba_ip_janeiro_2013_59085109 65119113825184.pdf; DGTF 2009 Loures concession data sheet http://www.dgtf.pt/ResourcesUser/PPP/Documentos/saude/saude_est_loures. pdf; Vaz, A 2013 http://www.dn.pt/inicio/portugal/interior.aspx?content_id=3000608. Health and Economics Analysis for an Evaluation of the Public Private Partnerships in Health Care Delivery across EU 85 Project Case Study Hospital Dr José de Almeida, Cascais, PORTUGAL 1. Introduction This case profile should be read in conjunction with the country study of health PPPs in Portugal. The 277-bed Dr José de Almeida Hospital in Cascais opened in February 2010 in Alcabideche, Cascais, 25-km west of Lisbon to serve a population of 170.000. The Cascais hospital is an integrated acute general hospital providing a broad range of services to SNS users with a staff of 975 in 2011, including 200 physicians and 338 nurses (HPP 2011). The project was the first and the smallest of four new hospitals contracted by the SNS, (Sistema Nacional de Saúde) the Portuguese national health service, under the integrated hospital or “Cascais model” which includes both the design, building, financing and operation of the hospital facilities as well as the delivery of clinical services, under two different contracts. The new hospital absorbed and replaced an aging 155 bed hospital in the city centre, its construction took for 24 months, and it was achieved on time. The project cost was €99.2 million, with the hospital infrastructure valued at €67 million and the clinical services at €32.2 million. The hospital facilities and the clinical establishment revert to the SNS at the respective contract term. In 2011, its first full year of operations in the new facilities, HPP Parcerias Saúde, the CliniCo reported production of 4.057 conventional surgeries and 3519 ambulatory surgeries, 14,698 in-patients and 120.873 outpatient visits and revenues of €68,6 million and a negative EBITDA, (earnings before interest and taxes) of -€2,2 million (HPP 2011). The hospital is located within the ARSLVT (Administração Regional de Saúde Lisboa e Vale do Tejo, regional health unit of the SNS) covers about one seventh of the national territory but about 34% of total population. About 17,9% of the ARSLVT population was age 65 as over , as of 2008, reflecting the fact that Portugal is one of the countries with the highest average age in Europe (INE, ARSLVT). 2. Type of Contract and Key Design Features – Cascais twin-SPV integrated hospital model As described in the Portugal country summary, Cascais was the first bundled integrated PPP hospital contact to reach financial close in February 2010, consisting of two contracts with twin-SPVs: a 30-year contract for the infrastructure and facility services and a 10-year contract for the clinical services. The bundling of clinical services within the hospital PPP in Portugal contrasted with the prevailing infrastructure-only PFI model and posed key challenges with lenders and investors. (Project Finance International 2010).
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Sustainability from the perspective of the ARSLVT and the SNS are also been considered acceptable by