ابتکار امور مالی شخصی، شکل پروژه و نوآوری طراحی: برنامه بیمارستان های بریتانیا

This paper discusses the role of public demand, in the form of a government procurement policy, in generating innovative solutions for healthcare infrastructure. It considers the effects of the project delivery system (planning, finance, construction and operation) for new hospitals on design innovation. It focuses on hospitals built under the UK's private finance initiative (PFI), which was partly introduced to inject increased innovation into hospital delivery. We use case studies of six early PFI hospitals to argue that the introduction of PFI has increased the complexity at the interface between project delivery and hospital operational functions. The result is a project delivery model which yields less innovative outcomes and produces facilities that might not be able to cope with future changes in demand. The paper suggests that new public procurement models do not automatically provide efficiency and innovation benefits.

Increased interest in the use of ‘public demand’ to secure innovative solutions and products, and improve the delivery of public services, was recently highlighted by Edler and Georghiou (2007). Drawing on earlier work by Dalpé et al. (1992) which shows how the state often acts as a lead user in stimulating innovation, Edler and Georghiou argue that public procurement is one of a range of measures for delivering innovative public infrastructure and services. The UK is highlighted for its systematic and advanced approach, with the procurement strategies of the National Health Service (NHS) singled out as leading examples of efforts to change practice. This paper extends the work of Edler and Georghiou by empirically examining the use of the ‘private finance initiative’ (PFI) to procure and operate new NHS hospitals. This is currently the main procurement route for this type of healthcare infrastructure, and one which government has endorsed as a means of stimulating innovation. Specifically, we investigate the relationship between the project delivery system (the relationship between the funders, contractors and the public sector client) and design innovation. Design innovation is seen here in terms of physical adaptability—the ability of a building to economically accommodate future changing requirements. This has been a long-standing challenge in the provision of healthcare infrastructure, where technologies, policies and services are subject to much shorter lifecycles than that of the relatively inflexible built assets that support them. The need for adaptability was reiterated in 2001 by the then Secretary of State for Health, who argued that innovative new hospital designs could help raise care standards and ensure the flexibility needed to plan for future medical advances (Dept. of Health, 2001). The study draws on a conceptual framework for exploring project delivery within the rail transport sector developed by Geyer and Davies (2000). Applying this model to the healthcare sector, we argue that in its current form the PFI model is unable to promote the level of innovation in the design of hospital built assets needed to optimise their lifetime clinical efficiency. This is partly due to the relationship between (1) the project delivery and (2) hospital operational systems. Through six case studies of new PFI hospital projects, we suggest that instead of promoting a higher degree of integration between the project delivery and hospital operational systems, the introduction of PFI has resulted in a separation between them. This has led to problems such as disrupted communications, complicated patterns of collaboration, misaligned goals and incentives and poor inter-project learning. The result is a project delivery model which may be producing facilities that are unable to adapt to future healthcare needs and health service innovations. The next section provides a definition of ‘adaptability’, explains its importance with regard to current hospital developments, and argues that in this context adaptability can be regarded as innovation. We then outline the debate on the use of public demand as an engine for innovation and consider the emergence of PFI as a procurement vehicle for modernising the UK's healthcare infrastructure. The following section describes a conceptual framework for understanding the relationship between PFI as a project delivery mechanism and innovation in hospital design. We also outline three potential reasons why innovation might be hard under PFI, in its current configuration. These relate to the complexity at the interfaces between the various components of the hospital project–operational system, the allocation of risk and rewards within this system, and the impact of PFI on opportunities for intra- and inter-project learning. These questions are then discussed using findings from the six case studies. Finally, we draw conclusions on the policy and practice implications of the empirical findings and the usefulness of the conceptual framework.

Edler and Georghiou (2007) argue that there is a need to place ‘public demand’ more centrally within innovation policy and use it to complement supply side measures. We have explored the reality of a public procurement model that is currently targeted at the delivery of hospital infrastructure. We found that in its current form, PFI may have been less effective in stimulating design innovation than the model it replaced, which involved greater coordination across individual project and operational systems, and across geographical boundaries. Increasing the role of the private sector in the delivery of public infrastructure projects has therefore not provided the innovation benefits desired by the UK government. This is not to suggest that PFI or other variants are incapable of delivering innovation. It should be noted that the selected case studies were all early examples of PFI hospital schemes. It is possible that later projects have demonstrated learning and improved innovation outcomes. An updated model, ‘smart PFI’, is also currently being introduced, in which the design phase is removed from the PFI tendering process in order to allow greater discussion about alternative solutions. However, the main structural problem – a separation of the project supply side, through the private sector consortium, and operational services delivered through the NHS – remains unresolved. To overcome this, the SPV should incorporate a coordinating and integrating function that furthers the relationship between project supply and clinical operations, rather than restricting it. We believe that policy makers should not only ‘learn the readiness of industry to deliver innovations’, as suggested by Edler and Georghiou (2007, 959), but they should also incentivise industry to deliver innovation. A public–private delivery model that includes incentive mechanisms for the partners to consider quality and efficiency improvements in the hospital's care outcomes (e.g. length of stay, hospital acquired infection rates) might be far more effective in helping to exploit the innovative potential of the private sector in providing healthcare infrastructure.