THE CANADIAN COUNCIL FOR PUBLIC-PRIVATE PARTNERSHIPS. The Canadian Case for Hospital PPP Projects

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1 THE CANADIAN COUNCIL FOR PUBLIC-PRIVATE PARTNERSHIPS The Canadian Case for Hospital PPP Projects

2 In 1999, 73 percent of UK public construction projects exceeded the price agreed at contract and 70 percent of the projects were delivered late. In 2002, only 22 percent of Private Finance Initiative Projects exceeded the price agreed at contract and 24 percent were delivered late. 1 The international experience in hospitals and other infrastructure areas has been that specifying outputs rather than inputs leads to more creative design, cost-savings and lower life-cycle costs of approximately 20% to 30%. 2 The federal government should encourage the provinces and territories to explore public-private partnerships as a means of obtaining additional investment in hospital capacity. 3 1 PFI Construction Performance, UK National Audit Office, February ) Value for Money Drivers in the Private Finance Initiative, Arthur Andersen and Enterprise LSE, January 2000; 2) Durham Veterans Affairs Medical Center Case Study; 3) The Economics of the Private Finance Initiative in the NHS, John Sussex. 3 The Health of Canadians The Federal Role; Volume Six: Recommendations for Reform, The Senate Standing Committee on Social Affairs, Science & Technology, October 2002.

3 The Canadian Council for Public-Private Partnerships The Canadian Case for Hospital PPP Projects 2003 The Canadian Council for Public-Private Partnerships November 2003

4 05 Table of Contents FOREWORD 07 GLOSSARY 08 EXECUTIVE SUMMARY 09 INTRODUCTION SETTING THE STAGE Health Care in Crisis? Jurisdictional Responsibilities A Role for PPPs in Hospital Capital Projects and Non-Clinical Services 15 ANALYTICAL FRAMEWORK BUILDING BLOCKS FOR HOSPITAL PPP PROJECTS Design Build Finance Operate ALTERNATIVE PPP STRUCTURES RISK MEASUREMENT AND ALLOCATION Risk Measurement Risk Allocation APPLYING THE PPP MODEL TO THE CANADIAN HOSPITAL SECTOR GLOBAL EXPERIENCE WITH PPP STRUCTURES 28 CASE STUDIES CASE STUDIES - OVERVIEW U.K. HOSPITAL PPP EXPERIENCE 33 Background 33 Case Study 1 Ferryfield House (Scotland) 36 Case Study 2 Cumberland Infirmary (Carlisle) 39 Case Study 3 Darent Valley Hospital (Dartford and Gravesham) AUSTRALIAN HOSPITAL PPP EXPERIENCE 53 Background 53 Case Study 4 Mildura Hospital 55 Case Study 5 La Trobe Regional Hospital U.S. HOSPITAL PPP EXPERIENCE 62 Background 62 Case Study 6 Durham VA Medical Center & Veteran's Hospital CANADIAN DOMESTIC EXPERIENCE 66 Case Study 7 East Coast Forensic Hospital 66 Case Study 8 University Health Network Bond Offering 71 Case Study 9 Royal Ottawa Health Care Group CANADIAN EXPERTISE EXPORTED 77 Case Study 10 Shaikh Khalifa Medical Centre, Abu Dhabi, United Arab Emirates 77

5 THE CANADIAN CASE FOR HOSPITAL PPP PROJECTS 06 IMPLICATIONS FOR CANADIAN HOSPITALS ASSESSING AND RANKING PREFERRED PPP MODELS Private Capital Investment Private Capital Renewal Mixed Private and Public Operations and Maintenance Public Asset Ownership Commercial Risk Ranking PPP Models ACTION STEPS FOR CANADIAN HOSPITAL PPP PROJECTS Developing Pilot Projects Developing an Appropriate Financing Model Identifying Champions Capable Private and Public Sector Proponents ( Intelligent Client ) Proving Value for Money Risk Identification, Allocation and Management Engaging Prospective Bidders Legislative Reform SETTING REASONABLE EXPECTATIONS CONCLUSION 90 APPENDIX A: HOSPITAL SPENDING 91 APPENDIX B: DESCRIPTION OF PPP MODELS 93 TABLE OF FIGURES FIGURE 1: SPECTRUM OF P3 OPTIONS 22 FIGURE 2 RANGE OF BASIC PPI OPTIONS 22 FIGURE 3 VALUE FOR MONEY 24 FIGURE 4 CASE STUDY MATRIX 30 FIGURE 5 GENERIC HOSPITAL DBFO CONTRACTUAL FRAMEWORK 31 FIGURE 6 ALLOCATION OF RESPONSIBILITIES AND RISKS IN PPP STRUCTURES 81 FIGURE A1 OPPORTUNITIES FOR PRIVATE INVOLVEMENT IN HOSPITAL OPERATIONS 91 FIGURE A2 OPPORTUNITIES FOR PRIVATE INVOLVEMENT IN HOSPITAL CAPITAL AND OPERATIONS 92 THE CANADIAN COUNCIL FOR PUBLIC-PRIVATE PARTNERSHIPS

6 09 Executive Summary Canadians are fiercely proud of their health care system. Yet with health care costs approaching $100 billion per year and annual operating costs accounting for almost 50% of a province s budget, the system is arguably unsustainable. At the same time, in the face of extended periods of under-investment and an aging population, there is a critical need for capital investments in infrastructure, IT and medical equipment. This paper addresses a potential role for the private sector in designing, building, financing and possibly operating infrastructure renewal and investment in the Canadian hospital system. To be clear, the paper does not in any way recommend or advocate any potential private sector role in the delivery of insured clinical care services. Analytical framework In discussing whether public-private partnerships ( PPPs ) are a viable option for hospital projects in Canada, this paper first provides a theoretical analysis of the key components of PPPs building blocks, structures and risk measurement and allocation and how these could be applied to the Canadian experience. To be feasible, a PPP must demonstrate greater value for money than available under public procurement. As with any PPP, the preferred structure for a hospital capital project depends on identifying the model which best allocates resources, risks and rewards. The analysis concludes that the Design-Build-Finance-Operate ( DBFO ) model has merit. Case studies The paper turns to an empirical analysis of ten international hospital PPP projects. In the U.K. and the State of Victoria, Australia, PPP projects are managed through the Private Financing Initiative ( PFI ) and Partnerships Victoria respectively, and several cases are drawn from their experience. Other cases are from Canada, United States and United Arab Emirates. For each case study, a description of the facts (rationale, partners, structure) is followed by a discussion of the project issues and lessons learned. The cases use a range of different PPP models (including DBFOs), and illustrate common success factors and common growing pains. They demonstrate that hospital PPPs can deliver value for money.

7 THE CANADIAN CASE FOR HOSPITAL PPP PROJECTS 10 Implications for Canadian hospitals The analytical framework and the case studies suggest that the preferred PPP model for Canadian hospital infrastructure projects would feature private design and construction, private capital financing or investment, mixed public and private operations and maintenance, eventual (if not immediate) public ownership, and the private assumption of a substantial degree of risk. The PPP model that best meets these requirements is DBFO. Aspects of DBFO models for hospital infrastructure projects have been tested in isolation in Canada. What is required now is the political determination to allow testing of a more integrated model. Action steps to move forward with Canadian hospital PPP projects include: 5) In order to prove value for money, develop a methodology for how to value and allocate risk. 6) Engage prospective bidders by facilitating the PPP process, e.g. Cabinet approval before tendering, standardized contracts. In conclusion, PPPs may be a valuable option for Canadian hospital capital projects and non-clinical services, given the appropriate social, regulatory and political environment. Further, they can be delivered without compromising clinical care or offending union collective agreements. Ultimately PPPs may provide the infrastructure renewal necessary to advance, not threaten or dismantle, the delivery of clinical care by provinces within the ambit of the Canada Health Act. 1) Develop pilot projects to test, refine and adapt the PPP model for broader implementation. 2) Develop an appropriate financing model, including any legislative reform required. 3) Identify champions political, bureaucratic and within the hospital sector. 4) Develop private and public sector expertise in the complex and burgeoning field of PPPs (an intelligent client ). THE CANADIAN COUNCIL FOR PUBLIC-PRIVATE PARTNERSHIPS

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