Select Committee on Health First Report


IV THE PRIVATE FINANCE INITIATIVE

What is the Private Finance Initiative?

54. The Private Finance Initiative (PFI) is a particular type of Public Private Partnership and was launched in 1992 by the then Conservative Government to harness the benefits of private sector finance and services for the public sector. The principle of the PFI is that a public sector body obtains a service rather than an asset. The public purchaser, in this case the Department of Health, defines the "outputs" that it seeks, in other words the services it requires, and invites private sector bidders to "present their solutions to meet these service needs".[82] As the Department put it:

    "In health this means the public sector delivering high quality clinical services in NHS hospitals, while the private sector provides innovation, management skills and financing to manage the infrastructure."[83]

55. The commissioning authority avoids the need for capital expenditure at the beginning of the project in exchange for making payments for the service as it is delivered. The presence of the words "private finance" in PFI has caused some confusion. In the end the costs of PFI constitute public expenditure, since the service payments are met from public funds. The Institute for Public Policy Research (IPPR) in a recent study of Public Private Partnerships, helpfully drew a distinction between the method and source of payment:

    "To understand why the PFI in no way relaxes the resource constraints faced by government it is necessary first and foremost to grasp the difference between finance and funding for a project ... In purchasing a car many people will use private finance, that is, they will borrow from a financing company the sum necessary to drive the car away. However, they will have to find the funding for this purchase from their own income, probably paying monthly instalments back to the financing company. That institution does not in the end provide a single penny of actual resource. It is the same with PFI. Although the finance ... comes from the private sector all the funding comes from the public purse."[84]

56. The PFI will only be the preferred option when it is shown, in the view of the Department, to offer better value for money than conventional procurement.[85] When the Department believes this has been demonstrated an NHS trust enters into a contract with a private sector consortium for the supply of a new asset, for example a new district general hospital. The consortium designs, builds, finances and operates the hospital and the trust provides clinical and clinical support services. The trust's existing assets and services are transferred to the consortium. In return for delivery of the contracted services, including for example the availability of hospital facilities, the trust incurs an annually adjusted charge which it pays to the consortium in monthly instalments. This is done on a lease basis the length of which would normally run for 30 years.[86]

57. In its 1997 and 2001 election manifestos, the Labour party committed itself to continuing with PFI to pursue its health objectives.[87] The present Government's approach to using the PFI process has not been half-hearted. Across government, departments have utilised PFI and the Department of Health is no exception. According to the Department's Annual Report for 2001-2, "on current plans PFI will provide nearly £800m worth of capital investment in 2001-2".[88] Some 64 major PFI hospitals have been approved since May 1997. Eight are now complete and operational and 15 others have reached financial close and are under construction. During the same period only four schemes 'failed' the value for money test, and are to be conventionally procured.[89] In addition, a number of smaller schemes for community and mental health facilities are now in the pipeline - over 50 schemes with values below £25 million have reached financial close.[90]

58. The Department claimed that PFI was providing an unprecedented level of capital investment for the NHS - "the biggest hospital building programme the NHS has ever seen" in the words of the Secretary of State - and the majority of this was coming through PFI projects.[91] While the need for this investment is not in dispute - large-scale investment in the NHS is seen across the board as necessary - there is a fierce debate about whether PFI is the appropriate way to finance capital investment, and whether it will provide the value for money that its supporters claim.

The debate on PFI

Claims and counter claims

59. Although our inquiry looked at public private partnerships of all kinds in the NHS, we received most evidence on the PFI. A wide range of organisations and interested parties gave evidence. Even a cursory examination of this material suggests how polarised the debate has become, with exaggerated claims being made on both sides of the argument in a climate not always conducive to rational analysis. Supporters of PFI have promoted it as the only solution to the problems of the cost and time overruns they regard as synonymous with public sector procurement, and the best means of addressing the large backlogs of essential maintenance of the NHS estate.[92] So, for example, the CBI asserted that the debate on PFI needed to move beyond the technicalities of the cost of the PFI against an artificial public sector comparator to "recognise the benefits of innovation in service delivery, facilities being delivered on time and on budget, assets being properly maintained and the value for money gains over time that come from a diverse and contestable market".[93] KPMG argued that "PFI has led to a higher standard of hospital accommodation that has been delivered more quickly than under conventional procurement".[94] The Business Services Association asserted that private sector involvement in hospitals would also allow for innovation in working practices and purchasing regimes that would, along with service measurements, ensure higher quality services.[95] The Department itself listed three "structural benefits" of PFI: that it transferred the risk of time and cost overruns to the private sector; that the fixed payments over the life time of a contract made for easier planning; and that payments for the service were linked to quality standards, thus providing an incentive to the contractor to offer high standards of maintenance. The Secretary of State described PFI as "a huge success story for the NHS".[96]

60. However, many stakeholders disagreed with this view. UNISON felt that the PFI had not been shown to afford value for money and called for a moratorium on its use and an independent review of all current schemes.[97] The Medical Practitioners' Union told us that PFI projects were "poor value for money, led to less beds and staff and to cramped, poorer premises".[98] Mr T G Fellows, a former Chair of the Oxfordshire Community Health Council, concluded that PFI finance was expensive, its value for money analyses were "untrustworthy", its building quality claims "implausible" and that it had inherent ethical problems.[99] The Royal College of Nursing (RCN) was another body who thought that the economic case for PFI had not been made, voicing its concern that "the method of costing a traditionally procured NHS hospital is over-inflated" with the consequence that the total costs to the NHS over the term of a PFI contract were "excessive".[100] However, the Business Services Association stated the reverse.[101]

61. These opposing positions were replicated at a local level when we visited two of the first wave of PFI hospitals in Carlisle and Durham.[102] In Durham, in addition to the written evidence we received on the North Durham PFI we also took oral evidence from representatives of the Trust, the private sector partner and the unions. The two sides of the debate were clearly reflected at this session.

62. The trades unions in their submissions had painted a sorry picture of the North Durham PFI project. In written evidence, the GMB and UNISON cited numerous faults in the new hospital, and attributed many of them to the PFI. These included generator failures plunging operating theatres into darkness, overheating, poor planning, and plumbing faults which resulted in sewage flooding through ceilings.[103] UNISON also cited examples of poor planning: the location of sluice areas adjacent to the wards, the absence of a proper waiting area by the mortuary, a lack of natural light and ventilation and inadequate air-conditioning.[104] It was the unions' view that many of these faults were directly attributable to the PFI process. However, these accusations were strongly disputed by the Trust and its private sector partner, Consort Healthcare. In its memorandum Consort Healthcare conceded that there were initial problems, but rejected the accusation that these were inherent to the PFI project.[105] Mr Steven Mason, chief executive of the Trust, dismissed many of the complaints as "urban myths" and submitted a detailed statement on the position.[106] Most of the accusations levelled against the hospital, he felt, could more accurately be described as "minor teething problems ... that are inevitable when moving into such a complex facility".[107] While we accept that there were problems we believe that they were exaggerated.

63. It is difficult to steer a course through this field of claim and counter claim, and perhaps it does not further the debate on the merits of PFI. PFI is a complex subject with long-term implications. As its promoter, the Government has to convince the wider public that it is not just a viable option in terms of value for money for the taxpayer, but also that it presents an opportunity to improve the quality of healthcare provision. The success of such projects will be affected by the perception of them by the wider public and the Department has not been altogether successful in presenting its case. The Secretary of State admitted as much to us:

    "I think we have to be blunt about our own failures, across government we have not successfully defended PFI as well as we should have."[108]

64. The Government needs to address this failure. We were also disappointed at the lack of evidence backing many of the claims made. Despite numerous requests to the private sector for examples of innovation in management we received few. We are not convinced that there is a vast pool of more talented people in the private sector compared with the public, and any implication that there is undermines the public sector. Whilst always inviting new ideas we recommend the Government accepts there are skills in both sectors and amends its stance in this light.

65. We were unimpressed with much of the University College London's Health Policy and Health Services Research Unit's (HPHSRU) research and its arguments[109] against the Private Finance Initiative. Its arguments have confused criticism of capital charges introduced in 1991 with criticism of the PFI. Some of the Unit's criticisms, for example its concern over NHS planning, were mainly criticisms of capital charges and were not largely attributable to PFI.

66. The HPHSRU's claims that there had been no checks against any of the value for money tests were untrue, since the National Audit Office had completed at least one such study. In evidence Professor Pollock's assertion that "There is a new pact with big business which is not operating currently in favour of the population"[110] was so extreme as to undermine confidence in the analysis and conclusions of the Unit's report. Similarly, the Unit's claim that PFI involved writing an "open-ended cheque paying four, five or six times more than we should" was not backed up by the evidence we received.[111]

67. Furthermore, the HPHSRU's assertion that it was never a good thing in the NHS to have increased capital charges funded by a revenue budget, for example by staff savings, was dubious. Many projects in the NHS, such as MRI scanners and ward reconfigurations, fall into this category and have led to better patient services. This has raised serious questions about the HPHSRU's ability to analyse rationally the finances of the NHS. An MRI scanner, by scanning patients more quickly, could allow patients to have a better service whilst reducing the need for radiographer time, which could at least in part, pay for the additional capital costs.[112]

68. We found the lack of sound analysis from the HPHSRU additionally worrying because it has been the source of advice for many groups including unions and professional associations, all of whom have used parts of the Unit's work as a justification for their antagonistic attitudes towards the private sector. We recognise that there are potential problems with PFI, but we also can see its potential benefits. At the very least a benefit could be getting more NHS services now, for a cost over the lifetime of a project, should none of the risks come to fruition. Against this possible cost we recognise that the cost of not having NHS services immediately needs to be weighed, which is a cost for patients and the community.

69. The Government has not helped by appearing to assert that private finance and management can always add to the public sector. Similarly some of the antagonistic extreme views that are put forward by the HPHSRU and by other organisations have not helped to promote a sensible and mature debate about what is best for patients and staff in the NHS.

70. PFI is still being blamed for numerous ills not directly related to it whereas the many benefits ascribed to PFI have yet to be proved. The time has come for a more rational and objective debate, and it is the responsibility of the Government to take the lead in achieving this. In order to achieve this there has to be more transparency, openness and accountability, points we develop below.

Bed numbers

71. The impact of PFI on bed numbers is a stark example of where the debate on PFI has become polarised. Opponents of PFI contend that the financial constraints imposed by PFI projects drive down the number of beds a trust can afford, whereas supporters of PFI maintain that bed numbers are determined entirely independently of the chosen method of procurement.

72. Most of the evidence we received from bodies representing health workers suggested that bed reductions and PFI were inextricably linked. The RCN argued that bed numbers appeared to be lower in PFI projects. In a recent survey of RCN members involved with PFI projects, staff in all of the larger schemes (greater than £25 million) reported a decrease in bed numbers.[113] UNISON was particularly concerned about the impact of the first wave of PFI Projects on bed numbers.[114] The GMB also reported similar experiences.[115] Professor Allyson Pollock was in no doubt that PFI did have an impact on bed numbers.[116] Her studies led her to conclude:

    "It was notable that all PFI schemes involved major reductions in acute bed numbers and services and that rehab and longer stay beds are being closed to fund PFI hospitals."[117]

73. Again, this argument was played out to us when we visited Durham and Carlisle. At Durham we took oral evidence from those directly involved in the new hospital. Commenting on the development stages, UNISON recalled that the original project in 1991 had envisaged a centralised hospital service in a 900-bed district general hospital. Since then, in its view, every stage in the procurement process had been associated with a reduction in bed numbers with the consequence that the final figure for beds had fallen to 454. In addition to the headline reduction, UNISON maintained that the cost of the PFI payments had also forced a reduction in clinical staffing budgets with the result that only 350 beds would be staffed.[118] Mr Robin Moss, Head of Health for UNISON's Northern Region, acknowledged that many factors affected bed numbers but told us that he remained convinced that the "number of beds in the hospital was tailored to the financial equation, not to health needs".[119] This was strongly disputed by the trust which averred that "bed numbers would have been the same under the public sector option".[120]

74. The presence of a direct link between bed reductions and PFI was denied by both the Department and those trusts involved in PFI projects. When we questioned the Secretary of State on the relationship between PFI projects and bed numbers he argued that the reduction in bed numbers had been occurring for decades before PFI. He told us that the idea that PFI equated to bed cuts was "simply wrong and not borne out by the evidence".[121] Mr Norman Rose of the Business Services Association, a trade body representing most of the major private sector companies involved in PFI, confirmed the evidence of most of the trusts we spoke to:

    "[any] decision on beds is made by the Trust, and solely by the Trust, before the outline business case comes out; we have no hand in it at all. When bids come in from the variety of companies, or consortia, who are asked to bid, if at that stage the Trust then decides that the cost is higher than the budget the Trust has, then the Trust itself may decide to look at reducing the number of beds; we have no role in this and we wish no role in it."[122]

75. However, Ms Jane Herbert, Chief Executive of South Manchester University Hospitals NHS Trust, said that PFI did influence bed numbers, albeit indirectly. The increased pressure on cash flow, which she associated with PFI, had resulted in more pressure in the system generally, though she thought it would be wrong to characterise it as a "driving factor". When pushed for an illustrative figure for the impact of PFI on bed numbers she estimated "maybe 10 per cent more pressure because of the PFI".[123] However, the chief executive of the nearby Central Manchester NHS Trust was confident that the new hospital for his trust would have an extra 190 beds and that this figure would have been the same regardless of whether it had used PFI or conventional funding. He felt the difference in emphasis between his position and that of Ms Herbert was a consequence of the fact that his was a later scheme and benefited from the major expansion in spending signalled by the NHS Plan.[124]

76. Several of our witnesses drew this distinction between the first wave of PFI and subsequent waves and in particular drew attention to the impact of the National Beds Inquiry (NBI). The NBI grew out of concerns within the Department that the long-term decline in staffed hospital beds might have gone too far.[125] Commenting on the conclusions, the Secretary of State said that the Inquiry showed "we need to take a whole-system view of services, and under any scenario, this is likely to require an increase in the number of beds in the whole system".[126] This meant that those PFI projects concluded following the NBI were not subject to the pressures evident in the first wave of PFI projects. Even Professor Pollock agreed that the National Beds Inquiry had reversed the policy of bed reductions, but she remained of the opinion that beds were still being closed.[127]

77. Those on either side of the argument are adamant in their assertions or denials that PFI has an impact on bed numbers. The planning process is designed to ensure that there is no impact: bed levels are set before the funding route for a hospital is determined. Central Manchester NHS Trust thought that PFI might exert an indirect pressure on bed numbers, though the other three trusts we questioned said that there was no connection between PFI and bed numbers. What is not in doubt is the fact that the lack of transparency in the PFI process has been partly responsible for the impression that PFI can be equated with a reduction in the number of beds. What may also be the case is that the PFI has provided a convenient scapegoat to be blamed for poor bed planning, something which we hope the National Beds Inquiry has addressed. From the evidence we have taken we do not believe that PFI necessarily leads to reductions in bed numbers. We recommend that the Government reinforces the planning rules for new hospitals by making it clear to trusts that there should not be any pressure to reduce the capacity of hospitals regardless of which funding mechanism is used.

PFI versus conventional public procurement: assessing Value for Money

78. In its memorandum the Department underlined the fact that value for money (VFM) had to be proved before a project could proceed down the PFI route. The only way to prove this with absolute certainty would be to build two identical hospitals, one using conventional, Treasury funding and the other PFI.[128] In the absence of this, the PFI has to be tested against a hypothetical model, the Public Sector Comparator (PSC). This value for money test compares the full life cost of public provision (the PSC) with that of the PFI alternative, and assesses the value of the risk retained by the public sector in both options.[129] Therefore, the PSC is basically a pass or fail test: if the net present value of the PFI bid is below that of the PSC then the deal is considered to be good value for money.

79. The value of the risk and its transfer from the public sector to the private sector is central to the value for money equation. As the Department explained: "PFI transfers the risk of time-and cost-overruns to the private sector, who are only paid once the facility is operating to the required standard. Publicly funded projects were often subject to delays and increased costs, and required extra capital to repair defects." Furthermore, "under the PFI contract the annual payments to the private sector partner are linked to performance and quality standards which is not possible under the conventional public capital funding route".[130] The Secretary of State made this point to us when he suggested that the only things which were privatised through the PFI were the cost overruns and the time overruns.[131]

80. Certainly the performance of conventionally procured projects has not always been impressive. Rectifying faults at St Mary's Isle of Wight is costing the NHS £20 million, and the cost of Guy's Hospital Phase 3 has risen 300 per cent and been delayed by over three years.[132] The Secretary of State believed that there were fundamental problems with publicly procured projects:

    "The point about the way that we procure traditionally through the public sector regime is there is no real incentive on the contractor to come in on time or on cost. By and large what happens in the real world is they know a new National Health Service hospital is a precious thing, precious to the trust and precious to the government and they assume that we will bail them out. The truth is that is what has happened. Chelsea & Westminster is a great example of that, we bailed them out, we are still bailing them out today as a consequence of that."[133]

However, major construction contracts include substantial penalty clauses in relation to time overruns and can limit the passing on of costs, although not to the same extent as is possible in PFI contracts. In the event of a PFI contractor walking away from a project the DoH would ultimately have to meet the additional costs of replacing the contractor or bailing out the project, as it would with a conventionally procured project. In reaching this position it is acknowledged that the PFI contractor will have incurred substantial losses.

81. As the risk is being taken on by the private sector, it has to be reflected in the VFM comparison between the PFI and PSC models. This is a complex calculation and as many people have commented, risk transfer is an art not a science. Risk valuation is not conducted to a standard procedure, but carried out on a trust by trust basis.[134] The Department explained that this was done because the individual trusts were best placed to understand local circumstances. The Department did, however, provide trusts with advice on how to quantify these risks and its PFI guidance outlines 22 typical construction and development risks. It also provided guidance on how individual risks could be allocated between the NHS and the private sector. [135]

82. The Institute for Public Policy Research suggested that some risks could be clearly assigned but others could not. In the view of the IPPR, design and construction risks (including time and cost overruns) and operating costs should be borne by the private sector partner, while the 'political' risks involved in changes to health policy should be borne by the public sector. However, risks associated with the demand levels for the service, and the obsolescence of technology in the project were far harder to assign.[136] Appropriate risk allocation between the public and private sector is a key requirement to the achievement of value for money on PFI projects. In its report on VFM in PFI deals the National Audit Office explained the importance of this:

    "Without risk transfer the private sector receive the benefit of a very secure income stream, similar to a gilt-edged security, but may set their charges at a level which earns them a return far higher than is available on such a security. However, if a Department seeks to transfer a risk which the private sector cannot manage, then the value for money will reduce as the private sector seeks to charge a premium for accepting such risks. [A department therefore should seek to achieve] not the maximum but rather the optimum transfer of risk, which allocated individual risks to those best placed to manage them."[137]

The IPPR agreed with this assessment: "Departments should strive for optimal risk allocation, not maximum risk transfer; whether this results in the project being off or on the public sector's balance sheet should be irrelevant to whether the project goes ahead".[138]

83. Several of our witnesses questioned the validity of risk transfers. The NHS Confederation believed that while any assessment of the true value of risk transferred could only be calculated once a contract had run its course, there remained a concern that some of the transfer of risk had not been particularly valid.[139] The Confederation also drew attention to recent work by the Office for Health Economics which suggested that the original claim that PFI procurement reduced the risk of cost overruns was open to question.[140] Professor Pollock argued that at the point when the contract is drawn up risk valuation was theoretical rather than real.[141] As an example of how this could unravel, she cited the Passport Agency's PFI deal with Siemens. Siemens Business Services were contracted to develop IT systems for the Passport Agency. Part of the contract included the transfer of risks of late delivery or system failure. When failure occurred it was valued at £12.6 million. Yet according to Professor Pollock, only £2.44 million was being paid in compensation by Siemens.[142] She further asserted that it was not possible to identify and cost risks which might arise over the course of a 25-35 year contract and therefore that it had to be a subjective judgement.[143] Professor David Mayston from York University also suggested it was difficult to assess the risks of PFI contracts in their present form. In order correctly to assess risk, he proposed that PFI projects should be unbundled into their component parts (that is, Design, Build, Finance, Maintenance and Operation), with separate tendering for each. Doing this "would provide the opportunity to purchase the constituent elements from the most efficient sources, with a much closer association between risk and reward than PFI projects at present provide".[144] This, he maintained, would provide a level of transparency that could "overcome the suspicion that PFI is driven mainly by ... political factors that are extraneous to the long-term needs of the NHS".[145]

84. Professor Pollock in a supplementary memorandum cited the research of Jon Sussex, Associate Director of the Office of Health Economics, who argued that, in Professor Pollock's words, " risk transfer is liable to exaggeration in PFI business cases" and that this "arises because of trusts' perception that there is no alternative to PFI when public capital is subject to tight cash limits. Trusts are therefore inclined to treat VFM as a hurdle they have to surmount rather than as an objective test".[146]

85. Valuation of 'risk' is the key determinant of value for money as between the PFI and Public Sector Comparator. Yet risk valuation is as much of an art as a science. It must, however, be clearly understood that saying that risk is difficult to value is not the same as implying that risk is somehow cost-free. It is not in the interest of the taxpayer to transfer as much risk as possible to the private sector since risk attracts cost. What is essential is that an optimal transfer of risk takes place, with the private sector partner taking only the risks it is best equipped to manage. Again, more transparency would be beneficial, so that the partner best able to manage the risk is identified.

86. Once the risk transfer has been assessed and apportioned, a public sector discount rate is applied to anticipated future cash flows to allow the 'present cost' of a project to be assessed. The IPPR explains:

    "payments from the public purse for the capital element of a PFI scheme will be made at a later date than is the case under conventional procurement. A payment made later effectively costs less so these future payments have to be discounted."[147]

87. The discount rate chosen for VFM purposes has for many years been set by the Treasury at 6% and is intended to represent the pre-tax long-term cost of capital for low risk purposes in the private sector.[148]

88. The VFM margin between PFI projects and the PSC is relatively slim, and according to the Department averages out at 1.7%.[149] Therefore, if the discount rate is revised downwards by a couple of points it could make the PFI route the more expensive option - all other things being equal, a lower net discount rate favours public procurement over PFI. Professor Pollock gave us an example of how a change in the percentage rate could dramatically affect the value for money of a PFI. She contended that the Carlisle PFI scheme showed a £1.7 million margin in favour of the PFI scheme against the PSC at a discount rate of 6%, but a margin against of £900,000 at a rate of 5.5% and of £13.6 million at a rate of 3%. The IPPR also stated that changes in the net discount rate could have a significant impact on the PSC. It therefore recommended that all PPP/PFI proposals should be subjected to a "sensitivity analysis to see whether different assumptions, for example about different forms of risk allocation or a different discount rate, would significantly alter the value for money assessment".[150]

89. We explored this point with Mr Nicholas Macpherson, Managing Director of the Public Services Directorate at the Treasury. Mr Macpherson explained that the net discount rate was currently under review as part of the review of the Treasury Green Book.[151] On the specific point of the influence of the level of the rate he agreed that if the rate was lowered, in isolation, that would indeed make conventional procurement more attractive than the PFI. However, he argued that the net discount rate was in fact being reviewed in a wider context which would also take into account issues such as the treatment of risk and uncertainty, both in terms of time and cost overruns, tax, and possible flow backs to the Exchequer from private operators. Looking ahead to the outcome, he said that he certainly would not conclude that the review would necessarily change the balance between the public sector comparator and PFI projects.[152]

90. Given the current discount rate was set when rates were higher, a lower rate may now be more appropriate. We recognise that other factors need to be considered in the current review but we would want to be assured that the fact that the calculations to establish the PSC are so complex is not being used as an excuse to manipulate the PSC to produce whatever result is needed. To stop such a view gaining credence we recommend that the National Audit Office should assess the PSC process as a matter of urgency in the light of any revision of Treasury accounting rules. It is essential that the calculations underlying the determination of the PSC are clear, and that the means by which VFM is established are transparent and in the public domain.


82   Ev 5. Back

83   Ev 5. Back

84   Building Better Partnerships: The Final Report of the Commission on Public Private Partnerships, 2001, pp. 79-80. Back

85   In paras 78 to 97 we consider whether the process assesses accurately value for money. Back

86   Q47. Back

87   Ev 5. Back

88   Cm 5103, para 4.12. Back

89   These are Rochdale, Berks and Battle (from whom we took evidence), Sheffield (Stonegrove) and Guy's and St Thomas's, Ev 6. Back

90   Ev 6. Back

91   Ev 1; Q82. Back

92   The NHS Plan estimates that the backlog of maintenance in the NHS now stands at £3.1 billion. Back

93   Ev 303. Back

94   Ev 118. Back

95   Ev 77. Back

96   Q91. Back

97   Ev 46. Back

98   Ev 295. Back

99   Ev 299. Back

100   Ev 55. See also Ev 351 and Ev 369. Back

101   See paragraph 92. Back

102   We visited North Durham Healthcare NHS Trust and Carlisle NHS Trust on 29B30 October 2001. Back

103   PS 11 (GMB) Annex (not printed). Back

104   Ev 49. Back

105   Ev 35-36. Back

106   Ev 31 Annex (not printed). Back

107   Ev 31. Back

108   Q82. Back

109   Q377. Back

110   Q483. Back

111   Q401. Back

112   Q395, Q396. Back

113   Ev 55. Back

114   Ev 50. Back

115   Ev 352. Back

116   Q403. Back

117   Ev 355. Back

118   Downsizing for the 21st Century, 1999, para 1. Back

119   Q160. Back

120   Ev 31. Back

121   Q1073. Back

122   Q362. Back

123   Q503. Back

124   QQ503-4. Back

125   Shaping the Future NHS:Long Term Planning for Hospitals and Related Services, para 4. Back

126   Shaping the Future NHS:Long Term Planning for Hospitals and Related Services, Introduction. Back

127   Q505. Back

128   Q1058. Back

129   Ev 279. Back

130   Ev 5. Back

131   Q82. Back

132   Ev 5. Back

133   Q98. Back

134   Ev 279. Back

135   Ev 280. Back

136   Building Better Partnerships, p. 83. Back

137   Examining the Value for Money of Deals under the Private Finance Initiative, Session 1998-99, (HC 739), para 2.11. Back

138   Building Better Partnerships., p84. Back

139   Ev 244. Back

140   Ev 244. Back

141   Ev 362. Back

142   Ev 363. Back

143   Ev 362. Back

144   Ev 324. Back

145   Ev 324. Back

146   Ev 371. Back

147   Building Better Partnerships, p.86. Back

148   Ev 279. Back

149   Q75. Back

150   Building Better Partnerships, p.100. Back

151   Q70. Back

152   Q1065. Back


 
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