This is the third of four articles on Britain's public-private partnership in health care

Growing numbers of health authorities and NHS trusts are carrying out service “reconfigurations” which involve the centralisation of services from two or more sites and the sale or downgrading of the other sites Where structural change requires major investment, the private finance initiative is the only method of financing it. However, the higher cost of the private finance initiative increases the cost pressures on the revenue budgets.1 The result is service contraction: on average, bed numbers are to be reduced by 31% over the next three to five years (table 1). It should be noted that, at a national level, there has been no reduction in acute beds since 1994-5 (figure).2

The relationship between new investment and service configuration raises questions about the planning process: who is making decisions on future services, and on what basis?3 When faced with questions about the relative importance of clinical and financial factors in service planning, the government has tended to argue that the crucial decisions are all made by clinicians Clinical directors are responsible for agreeing and medical directors for approving full business cases; however, healthcare planning has never been a core clinical competence, and making decisions is very different from agreeing to decisions taken by others This issue was raised earlier this year in correspondence in the Glasgow Herald, in which the Scottish health minister responded to criticism of bed numbers at the controversial Royal Infirmary of Edinburgh private finance initiative scheme by stating, “It is the clinicians who decide on the number of beds…. The assumptions on bed numbers were developed …