Public Private Partnerships for Hospitals

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890 Bulletin of the World Health Organization |November 2006, 84 (11)

AbstractWhile some forms of publicprivate partnerships are a feature of hospital construction and operation in all countries withmixed economies, there is increasing interest in a model in which a public authority contracts with a private company to design,build and operate an entire hospital. Drawing on the experience of countries such as Australia, Spain, and the United Kingdom, thispaper reviews the experience with variants of this model. Although experience is still very limited and rigorous evaluations lacking,four issues have emerged: cost, quality, flexibility and complexity. New facilities have, in general, been more expensive than theywould have been if procured using traditional methods. Compared with the traditional system, new facilities are more likely to bebuilt on time and within budget, but this seems often to be at the expense of compromises on quality. The need to minimize therisk to the parties means that it is very difficult to future-proof facilities in a rapidly changing world. Finally, such projects areextremely, and in some cases prohibitively, complex. While it is premature to say whether the problems experienced relate to theunderlying model or to their implementation, it does seem that a publicprivate partnership further complicates the already difficulttask of building and operating a hospital.

Bulletin of the World Health Organization 2006;84:890-896.

Voir page 894 le rsum en franais. En la pgina 895 figura un resumen en espaol.

BackgroundTe delivery of health care in almostevery country involves some form ofpublicprivate partnership. In countries

where care is delivered mainly throughthe public system, many inputs, such aspharmaceuticals and support services,are sourced from the private sector. In

countries with predominantly privatelyowned facilities, the state influencestheir configuration through regulationsand financial incentives. In hospitals, thesituation is further complicated becauseof the many functions provided by suchinstitutions: the training of health pro--fessionals and research and development,for example, are activities that are pub--licly funded to varying degrees.1

However, even the concept of apublicprivate dichotomy is problem--atic. States often limit the scope of pri--vate contractors to decide where to placefacilities. Furthermore, there is a differ--ence between for-profit corporationsthat operate hospitals as one businessamong many and not-for-profit organi--zations (including religious foundations)that exist solely to provide health care.Tis paper will examine one particulartype of publicprivate partnership the

Publicprivate partnerships for hospitalsMartin McKee,aNigel Edwards,b& Rifat Atun c

895.

a European Observatory on Health Systems and Policies, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England. Correspondenceto this author ([email protected]).

b Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England.c Imperial College London, South Kensington Campus, London, England.

Ref. No. 06-030015

(Submitted: 3 March 2006 Final revised version received: 8 June 2006 Accepted: 5 July 2006)

construction of a health facility and theongoing provision of its non-clinical(and in some cases clinical) services

within a public system of provision.Private provision of essential public

services has a long tradition, especiallyin major infrastructure projects in thetransport sector and in the provision

of utilities. Te private sector played acrucial role in developing these servicesin the 19th century but, in the post-warperiod, many were taken into publicownership because of market failure.2

Privatization of public services be--came more widespread in the 1980s withthe emergence of a neoliberal consensusthat sought to reduce the role of thestate.3 In the health sector, however,comprehensive privatization was re--

jected because of the existence of marketfailure.4 Instead, various quasi-market

solutions were developed, typically theseparation of purchasers and providerswithin the public sector.5Te logicalnext step was to move the delivery ofhealth care out of the public sector. Tis

was seen as a means to increase value formoney, innovation, and responsivenessto users.6

Te conceptual underpinning of thisapproach was developed by Williamson7

and Ouchi,8with Preker et al.9applyingit to health care. Arguing that the publicsector is intrinsically less efficient and re--sponsive than the private sector, Preker etal. propose a matrix with one axis definedby the degree of contestability involvedin providing a service (i.e. ease of marketentry), while the other is defined by the ease

with which the outcomes of the service canbe measured.Where there is low contestability

and problems of measurement then aservice should be provided within amanagerial hierarchy; conversely wheremeasurement is straightforward andprovision is highly contestable it shouldbe purchased from the private sector.Supporters of this approach have strivento reduce barriers to market entry and toenhance the ability to measure quality.

Yet the basic premise is not borne out

by the evidence.

10

Australian researchshowed that, after adjusting for case mix,public hospitals are more efficient thanthose that are privately operated,11pos--sibly due to the more intensive manage--ment of patients in private hospitals.12

A systematic review identified 149comparisons of for-profit and not-for-profit health facilities (of various types)undertaken over the past two decades in


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891Bulletin of the World Health Organization |November 2006, 84 (11)

Special Theme Contracting and Health ServicesPrivately financed hospitalsMartin McKee et al.

the USA. Of these studies, 88 concludedthat non-profit facilities performed bet--ter with respect to cost, outcomes ofcare, access and social mission, 43 studiesfound no difference, and 18 reportedfor-profit facilities to be better.13

Publicprivate partnershipsto build and run hospitalsTe model in which a public authoritycontracts with a private company tobuild or run a hospital is, inevitably,seen mainly in countries with nationalhealth services. Various models havebeen developed (able 1). Australia hasthe most diverse range of models, withdiffering versions in several states.14TePrivate Finance Initiative (PFI) in the

United Kingdom is a design, build,finance and operate (DBFO) model. Ithas been the primary means of financingmajor capital investments in the health,education and prison sectors during thepast two decades. While this arrange--ment provided a source of much needednew finance, a great deal of this funding

was off-balance-sheet financing anddid not appear in the government booksas new borrowing. Tis arrangement en--abled the government to remain withintargets set for public sector borrowing.

Moves by the British Office for NationalStatistics to redefine such expenditure arelikely, at a stroke, to remove one of themain reasons justification for pursuingthe DBFO model.15

In the British model, a company usually in the construction sector willcreate a special purpose vehicle to bidfor a contract with a health authority tobuild and provide non-clinical services toa hospital. Te successful contractor willenter into three types of subcontract: one

with banks to finance the project; one

with a construction company to buildthe hospital; and one with a facilitiesmanagement company to manage it overthe lifetime of the contract, typically 30years. Over the lifetime of the contract,the health-care provider undertakes topay a defined amount from its revenuesand the contractor undertakes to main--tain the fabric of the hospital in goodorder and (depending on the agree--ment) manage facilities. Similar modelshave been adopted, although on a verymuch smaller scale, in Canada, Portugal

and Spain. It is also being introduced inIreland and, while not yet used to financehospitals, is used for procurement ofother infrastructure in Greece.16

Franchising is an alternative model,where a private company takes overmanagement of an existing publichospital. Tis approach has been triedin Sweden17 (including the sale of apublic hospital to a private company)

and in Italy. A unique model has beendeveloped in the Alzira Hospital, inValencia, Spain, which is managed by aprivate consortium that accepts respon--sibility for the health care for a definedpopulation in return for an annual percapita payment.

Tere is still relatively little expe--rience with these models of hospitalprovision, and governments have yet toundertake rigorous evaluations. Tusthe merits of these models compared

with the traditional model of provision

remain highly contentious but it isalready possible to identify several keyissues that have emerged. Tese are cost,quality, flexibility and complexity.

Key issuesCostTere are significant costs not only forthe firms bidding for a publicprivatepartnership, but also for the health-careprovider. Prospective bidders incur largecosts in developing their tenders, andlosing contenders must find a way ofrecouping their expenditure from sub--sequent contracts. A sequence of los--ing bids by a leading British companyinvolved in PFI deals led to fears ofinsolvency.18 Although the PFI pro--cess has been simplified by the use ofmodel contracts and other measures toreduce the very high level of complexity and thus the need for large amounts

Table 1. Models of publicprivate partnership in hospital provision

Model Description

Franchising Public authority contracts a private company to manageexisting hospital

DBFO (design, build, finance,operate)

Private consortium designs facilities based on publicauthoritys specified requirements, builds the facility,finances the capital cost and operates their facilities

BOO (build, own, operate) Public authority purchases services for fixed period (say30 years) after which ownership remains with privateprovider

BOOT (build, own, operate,transfer)

Public authority purchases services for fixed period afterwhich ownership reverts to public authority

BOLB (buy, own, lease back) Private contractor builds hospital; facility is leased backand managed by public authority

Alzira model Private contractor builds and operates hospital, withcontract to provide care for a defined population

of high cost legal, financial and othertechnical advice the process remainsdaunting for parties on both sides of thetransaction.

In theory, the British PFI modelshould contain the cost to the health

authority by transferring risk to thecontractors. But in practice, the cor--porate bonds used to finance PFI dealsare typically awarded BBB+ status byfinancial rating agencies, just above

junk bond status, while governmentbonds are considered less risky, and formany European governments attract

AAA ratings.19Te consequence of thislow rating is that the cost of borrowingmoney is higher than it would be forgovernments. A particular problem arises

with the way that the risks of construc--

tion are bundled with those associatedwith the operation of services. Whereasconstruction risks may be high and quitereal, the operation of services carries amuch lower risk, not least because hos--pitals are financially backed by govern--ment i.e. the government is a singlepayer, meaning that income streams tohospitals are less at risk than in markets

with multiple payers. However, somecontend that several of the risks factoredinto PFI business cases are unlikely ornotional and appear to be an account--

ing device designed to favour privateprocurement in cost comparisons withits public alternative.20Te reason forthis may have been a very strong signalfrom government that schemes relyingon public funding rather than PFI werevery unlikely to succeed.

Te low risk once constructionis complete has allowed advantageousrefinancing of projects at lower interest


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Special Theme Contracting and Health ServicesPrivately financed hospitals Martin McKee et al.

rates, with significant benefits to the PFIconsortia. Such activities have attractedunfavourable comment from the BritishNational Audit Office.21 Belatedly, theBritish reasury required that new con--tracts should incorporate provisions to

share these profits between the contrac--tor and the public authority.22

Te enormous size of some BritishPFI hospital projects has also been a causeof concern. Where this is the case, it mayreduce the level of competition betweenbidders as there are a relatively small num--ber of construction companies capable ofundertaking very large projects and thebidding costs can pose a significant bar--rier to market entry. One factor behindthe increasing size of projects may be thatconsortia have been unwilling to assume

the risk of modifying existing buildings.Building a hospital around existing build--ings and services increases the risks andcomplexity of construction. Because a PFIcontract is set up to deliver a single project,there is an incentive to load as much into ascheme as possible since additional capitalmay not be available in the future. Tus, therisks facing both parties are compoundedas the schemes become very much morecomplex, less financially viable, and theability to adapt flexibly to rapid changesin the health-care environment is limited,

as we discuss later in this article.Te cost of annual charges for build--ings constructed under publicprivatepartnership arrangements may behigher than the cost associated withhospitals built and run using conven--tional procurement methods. Some ofthis additional cost may be justified asthe National Health Service (NHS) inthe United Kingdom has had a poor

record of maintaining its buildings, withmoney meant for maintenance often be--ing reallocated to provide services. PFIcontracts ensure that money is put asideto properly maintain buildings. Tesecharges have also focused attention on

the costs of maintaining and operatingbuildings. Te legacy of buildings thatare expensive to run, clean, heat andrepair is a significant problem to theextent that some hospitals constructedin the 1960s and 1970s have alreadyreached the end of their useful life.Publicprivate partnerships can createan incentive for those involved in theconstruction of buildings to pay moreattention to these issues.

It is difficult to make accurate costcomparisons between the costs of PFI

procurement and more conventionalmethods. Pollock et al. have arguedthat privately funded initiatives aresignificantly more expensive than theconventional government funded ar--rangements for a variety of reasons,including the higher cost of financingassociated with lower credit ratings.23Tey also note the requirement for pri--vate companies to make sufficient profitto return to their shareholders. While theBritish government disputes the argu--ments against PFI, its case is weakened by

the lack of transparency that surroundsthese projects, which are deemed to becommercially confidential. Comparisonbetween the two procurement models isalso made more difficult by the need totake a life-cycle view to accommodate thetrade-offs between higher initial capitalcost and lower long-term operating costs.

Although the decision to proceed with aproject should be based on a process that

Box 1. Publicprivate partnerships facing financial problems

Alzira Hospital, Valencia, Spain26

In 1999 a consortium consisting of an insurance company, banks and construction companies was awarded a contract by the regional governmentof Valencia to construct a hospital to replace an obsolete facility. The hospital achieved high levels on standard measures of performance but wasafflicted by poor labour relations. It became clear that the contract was financially unsustainable and in 2002 a refinancing deal was arranged,providing a substantial financial injection. The hospital is now working well.

Paddington Health Campus, London, England27

A private financing initiative approach was chosen as the mechanism to consolidate several world-class teaching hospitals on a single site in westLondon. In 2000 an Outline Business Case estimated a cost of 300 million with completion by 2006. When the scheme eventually collapsedthe budget had risen to 894 million, with completion projected by 2013. Preparation of the failed project cost 15 million. The official reporthighlighted the extreme complexity of the project, unclear lines of accountability and a failure by central government to clarify whether it actuallysupported the scheme.

La Trobe Regional Hospital, Melbourne, Australia28

La Trobe Regional Hospital was built by a private company to replace older public hospitals, having entered into a confidential contract with the

government of the state of Victoria to provide hospital services for 20 years. In 1999 the hospital lost AUS$ 6 million and was projecting ongoinglosses. The Victorian health minister reported that the scale of losses was such that the hospital could no longer guarantee its standard of care. In2000 the company was released from its contract in return for an agreement to drop legal action against the government. It sold the facility to thegovernment for AUS$ 6.6 million (about half of its estimated valued) and made an additional payment of AUS$ 1 million.

compares the cost of a privately financedinitiative with a public sector option, thiscomparison is not always straightforward,

with the Assistant Auditor-General fromthe United Kingdom National AuditOffice describing this process as pseudo-

scientific mumbo-jumbo.

24

Although this section has examinedin detail the evidence from the UnitedKingdom, similar conclusions have beenreached in an economic assessment ofthe P3 hospital financing scheme inCanada, which shares many features

with the PFI model, including the se--crecy that shrouds contracts.25

Te costs involved in publicprivatepartnerships have frequently been un--derestimated. Box 1 provides examplesof several projects that have encountered

serious financial problems.

2628

QualityIn any procurement exercise, whenproblems arise there are trade-offs be--tween three variables: cost, time andquality. raditionally, the priority hasbeen to meet the specifications agreedin the initial contract, with a reluctantacceptance that the project may go overtime or budget. For example, in theUnited Kingdom in 2001, 76% of PFIprojects were delivered on time and 79%

within budget, compared with 30%on time and 27% within budget usingconventional procurement. With costand time seeming to be fixed in the PFImodel, concerns arise about the qualityof projects, with many of the hospitalsbuilt using this model experiencing sig--nificant problems (able 2).29,30

It is important to distinguish be--tween problems inherent in the PFI


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process and more general shortcomingsin the mechanisms for the planning andprocurement of new hospitals. It is pos--sible that some of the issues with PFI area more general feature of the design andbuild model used in the United King--dom, where public authorities, under

pressure to outsource key activities, haverun down their architecture and plan--ning departments. Instead of providingthe contractor with detailed drawings, abroad specification, which the contrac--tor can then interpret, is agreed. Tisapproach has led to a series of failures inseveral public sectors,31but also in privatesector procurement 32where firms havealso been under pressure to outsourcecore functions. Te expertise on the cli--ent side of the PFI process is relativelyunderdeveloped compared with PFI

consortia bidding teams. Whereas fewhealth authorities will have undertaken alarge capital development, the consortia

will have done several.A related issue is the bundling of

design with the rest of the PFI process.Although taking responsibility for designhas some advantages for the consortia interms of being able to control the risksand costs of construction, design fea--tures that benefit the user of the buildingrather than the operator may be less likelyto be incorporated. Design elements that

might create a more therapeutic environ--ment or an improved work setting forstaff are not always implemented. Tepressure to reduce building costs has

Table 2. Quality problems experienced with United Kingdom private finance initiative (PFI) hospital schemes

PFI development Problems29,30

Cumberland Infirmary, Carlisle Use of cheap components necessitating regular refitting Maintenance costs 50% higher than projections. Poor drainage and plumbing; and limited signage Patients leaving the cardiology department must go through five sets of swing doors, even though

most are in wheelchairs

Durham District General Hospital Pathology laboratory flooded three times in first 18 months, twice with raw sewage Poor ventilation and air filtration Fixtures and fittings are of poor quality; lightweight storage cupboards unable to take the weight of

routine equipment

Bishop Auckland Hospital Opening delayed by 2 months for modifications Generator and core electrical systems had to be redesigned immediately after opening

Norfolk & Norwich Hospital Negative pressure rooms were not properly operational for 2 years Air ducting found to be lying in unconnected lengths No ventilation in the kitchens so staff work in 30 C temperatures (with 44 C being recorded) Delivery loading bays inefficient

Hereford Hospital Boiler house opened with no water treatment plant Doors too heavy for the opening restraints Three lifts had to be refitted within 12 months of operation

Seacroft Hospital, Leeds Mental health facility found to have breached every section of the fire safety code

given rise to several buildings that lacknatural light and have other undesirablefeatures. Tese shortcomings need notnecessarily be a feature of publicprivatepartnerships; rather they are a reflectionof underdeveloped skills and an imbal--ance of power and knowledge between

client and contractor.

FlexibilityTe delivery of health care is changingrapidly, partly in response to altereddemands on health-care systems, suchas shifting patterns of disease and ris--ing public expectations, and also inresponse to the opportunities offeredby new technology.33 By contrast, thequest to minimize the risk to which theparties to publicprivate contracts areexposed has meant that the contracts areoften specified in very great detail, withlarge penalties for introducing changes.Tis lack of flexibility has meant thatthe configuration of some hospitalshas been out of date by the time theyare opened. Te problem is not uniqueto publicprivate partnerships but therigidity of contracts makes the solutionmore complex. In England, the difficultyof inflexible contracts has become moreacute as new policies, especially in health,have created a much less stable environ--

ment. For example, there is currently adeliberate intention to shift care awayfrom hospitals.34What would once havebeen variable costs are now fixed, so the

overall system has very little flexibility toadapt to the new circumstances.

Incorporating flexibility into theoriginal design is possible without add--ing costs for constructors or operatorsbut it does impose additional designcosts. Tere are few incentives for con--

sortia to build in flexible design solutionssince the cost of future modifications fallon the client. As noted previously, thebig bang nature of most publicprivatepartnerships makes it more difficult toadopt the modular approach to devel--opment that would provide more flex--ibility, although only issues that can beanticipated will be addressed.

ComplexityAlthough the use of publicprivate part--nerships has been effective when usedto finance transport infrastructure (buteven here there have been some high pro--file failures),35,36this success has yet to berepeated in the health sector. Te chal--lenges of implementing a publicprivatepartnership have been greatest in the caseof major teaching hospitals. Tese insti--tutions accept a wide range of referralsand provide services for various types ofpatients. As such, these projects involvemany different types of stakeholders.Tey also require the active participation

of universities and research funders. Tedifficulties in reaching agreement withall of these stakeholders, combined withthe high costs of the projects, have led


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References 1. McKee M, Healy J, editors. Hospitals in a changing Europe. Buckingham:

Open University Press; 2002. 2. Crompton G. Good Business for the Nation: the railway nationalisation

issue, 1921-47. J Transport Hist1999;20:141-59. 3. Savoie DJ. Thatcher, Reagan and Mulroney: in search of a new bureaucracy.

Pittsburgh, PA: University of Pittsburgh Press; 1994. 4. Arrow KJ. Uncertainty and the welfare economics of medical care.Am Econ

Rev1963;53:941-73. 5. Le Grand J, Bartlett W. Quasi-markets and social policy. London: Palgrave,

Macmillan; 1993. 6. Kikeri S, Nellis J, Shirley M. Privatization: the lessons of experience. World

Bank/ IBRD: Washington DC; 1992. 7. Will iamson OE. Markets and hierarchies: analysis and antitrust implications.

New York: The Free Press; 1975. 8. Ouchi WG. Markets, bureaucracies, and clans. Admin Sci Quarterly1980;

25:129-41. 9. Preker AS, Harding A, Travis P. Make or buy decisions in the product ion of

health care goods and services: new insights from institutional economicsand organizational theory. Bull World Health Organ2000;78:779-90.

10. Tittenbrun J. Private versus public enterprise: in search of the economicrationale for privatisation. London: Janus; 1996.

11. Duckett SJ, Jackson TJ. The new health insurance rebate: an inefficient wayof assisting public hospitals. Med J Aust2000;172:439-42.

12. Robertson IK, Richardson JR. Coronary angiography and coronary arteryrevascularisation rates in public and private hospital patients after acutemyocardial infarction. Med J Aust2000;173:291-5.

13. Vaillancourt Rosenau P, Linder SH. Two decades of research comparingfor-profit and nonprofit provider performance in the United States. Soc SciQuaterly2003;84:219-41.

14. Bloom A. Hospital co-locations: private sector participation in the hospitalsector. In: Bloom A (editor) Health reform in Australia and New Zealand.Melbourne: Oxford University Press; 2000.

15. Atun RA, McKee M. Is the private finance initiative dead? BMJ 2005;331:792-3.

16. Lethbridge J. European works councils and the healthcare sector. London:PSIRU; 2004.

17. Sveman E, Essinger K. Procurement of health care services in Sweden ingeneral, and the example of procurement of acute care in the StockholmRegion. In: European integration and health care systems: a challenge forsocial policy. Stockholm: Swedish Federation of County Councils; 2001.

18. News BBC. Jarvis to sell PFI bidding unit. Available from: http://news.bbc.co.uk/1/hi/business/3738716.stm

19. Treasury MH. OGC guidance on certain financing issues in PFI contracts.Available from: http://www.hm-treasury.gov.uk/media//6066B/PPP_GuidanceonCertainFinancing.pdf

20. Gaffney D, Pollock AM, Price D, Shaoul J. The private finance initiative: PFI inthe NHS. Is there an economic case? BMJ1999;319:116-9.

21. National Audit Office Report (HC 78, 2005-06). The refinancing of the Norfolkand Norwich PFI Hospital. London: NAO; 2005.

22. UNISON. Refinancing: profiting from public services. London: UNISON; 2001.23. Pollock AM, Dunnigan M, Gaffney D, Macfarlane A, Majeed FA, on behalf

of the NHS Consultants Association, Radical Statistics Health Group, andthe NHS Support Federation. What happens when the private sector planshospital services for the NHS: three case studies under the private financeinitiative. BMJ1997;314:1266-71

24. Anon. PFI/PPP conference (news). National Audit Office Focus. Availablefrom: http://www.nao.org.uk/guidance/focus12.pdf

25. Auerbach L. Issues raised by publicprivate partnerships in Ontarios hospitalsector. Ottawa: Canadian Health Coalition; 2002.

26. Lethbridge J. Public health section relations and deregulation in Europe.London: Public Services International Research Unit; 2003. Available from:http://www.epsu.org/IMG/pdf/Public_health_sect_and_deregul.pdf

Resumen

Alianzas publicoprivadas para los hospitalesAunque en todos los pases con economas mixtas surgen ciertasformas de colaboracin publicoprivada a la hora de construir ygestionar hospitales, cada vez suscita ms inters la opcin de que

una autoridad pblica contrate a una empresa privada para disear,construir y dirigir todo un hospital. A partir de la experiencia depases como Australia, Espaa y el Reino Unido, en este artculose analiza la experiencia adquirida con diversas variantes de esesistema. Aunque la experiencia es todava muy limitada y no sehan hecho evaluaciones rigurosas, han aflorado cuatro factores:costo, calidad, flexibilidad y complejidad. Los nuevos servicios hansido en general ms costosos que si se hubieran empleado los

mtodos tradicionales. En comparacin con el sistema habitual,los nuevos servicios suelen construirse respetando los plazos y elpresupuesto, pero ello se logra a menudo a expensas de la calidad.

La necesidad de reducir al mnimo el riesgo para las partes significaque es muy difcil crear servicios a prueba de acontecimientosfuturos en un mundo en rpida transformacin. Por ltimo, esosproyectos son extremadamente, si no prohibitivamente, complejos.Aunque sera prematuro afirmar que los problemas surgidos estnrelacionados con el sistema empleado o con su ejecucin, pareceque la colaboracin publicoprivada complica an ms la ya de pors difcil tarea de construir y dirigir un hospital.

. . . .

. . .

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Special Theme Contracting and Health ServicesPrivately financed hospitals Martin McKee et al.

27. National Audit Office. The Paddingtion Health Campus scheme: report by theComptroller and Auditor General. HC 1045. London: The Stationery Office;2006. Available from: http://www.nao.org.uk/publications/nao_reports/05-06/05061045.pdf

28. Parliament of Australia Senate Community Affairs Committee. The interfacebetween private and public hospitals. In: Healing our hospitals: a reporton public hospital funding. Canberra: Commonwealth of Australia; 2000.

Available from: http://www.aph.gov.au/SEnate/committee/clac_ctte/completed_inquiries/1999-02/pubhosp/report/c06.pdf29. Parliament UK. House of Commons questions 26 Jan 2006. Available from:

http://www.publications.parliament.uk/pa/cm200506/cmhansrd/cm060126/debtext/60126-32.htm

30. Hencke D. Private-finance hospital putting lives at risk. Guardian17 June2005. Available from: http://politics.guardian.co.uk/publicservices/story/0,11032,1508413,00.html

31. Glancey C. Anatomy of a disaster. Guardian. 1 March 2004 Available from:http://www.guardian.co.uk/arts/critic/feature/0,1159694,00.html

32. Chapman JC. Collapse of the Ramsgate walkway. Structural Engineer1998;76:1-10.

33. McKee M, Healy J. The role of the hospital in a changing environment. BullWorld Health Organ2000;78:803-10.

34. Department of Health. England. Your health, your care, your say. Availablefrom: http://www.dh.gov.uk/NewsHome/YourHealthYourCareYourSay/fs/en

35. Monbiot G. Captive state: the corporate takeover of Britain. London: Pan,2001.

36. National Audit Office. The Channel Tunnel rail link. Report by the

Comptroller and Auditor General. HC 302. London: The Stationery Office;2001.37. Vince N, Niven B.Lessons learned from the Paddington Health Campus

project: final report to the NWLSHA from the Independent Review Panel.London: North West London Strategic Health Authority; 2005.

38. House of Commons Defence Select Committee. Future carrier and jointcombat aircraft programmes: second report, 21 December 2005. London:UK Parliament; 2005.

39. Carvel J. PFI critic demands retraction after sloppy research accusation byMPs. Guardian1 June 2002. Available from: http://society.guardian.co.uk/privatefinance/story/0,8150,725882,00.html

Documents

Public Private Partnerships for Hospitals