Profiting from the NHSBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6990.1329a (Published 20 May 1995) Cite this as: BMJ 1995;310:1329
EDITOR,—Chris Ham seems gloomy about private finance for NHS trusts for building projects.1 This could, however, herald a new era, providing modern health service building without the restrictions of the public sector borrowing requirement.
A crisis is developing in the management of acute care through the reduction of trainees' hours of duty, the introduction of higher standards2 and new treatments, and, in my specialty, an acute shortage of candidates for consultant posts. It is essential, therefore, to concentrate emergency services on as few sites as practicable; this may mean rebuilding, which would also introduce an opportunity to provide the facilities required for the appropriate level of care.3
In the United States “not for profit hospitals” (analogous to trusts) raise money at interest rates that depend on their credit rating and are based on their history of repayment of loans, the status of the institution, and inspection of the project. NHS institutions have no such history, so that capital for whole hospital projects may either be subject to unsustainable interest rates or be unavailable. Fundholders will certainly, as Ham writes, have to give long term commitments to NHS trusts but cannot cover a pay back period of 20 years or more. Some unquantifiable risk will remain. Perhaps optimum terms could be arranged with a minority contribution of capital (but also repayable) from government funds. This subsidy would make schemes viable, producing a more reasonable residual value in the case of total loss (which must remain a possibility). This may seem impure but be a practical solution.
Ham also seems to be criticising private sector involvement in the control of trusts that borrow. The history of NHS capital expenditure is grim (for example, at the University Hospital of Wales, Cardiff, millions were spent on decaying facades and fire precautions), and there is widespread evidence of great waste in running costs.4 There is room for improvement in the management of both the capital project (which should be completed in time and at the cost stated in the contract) and subsequent recurrent expenditure. More careful scrutiny would therefore be welcome. It is up to purchasers to ensure that their objectives and standards are being met and that short term financial considerations do not receive undue weight. Instead of being looked on as selling off the silver this should be looked on as a golden opportunity for the health service to make rapid progress in updating building for the next century. But it will need the profession's and government action to make it happen.