The LIFT PPP Model
The LIFT PPP ModelProviding an estate for the 21st century NHSA research review prepared by The LIFT CouncilAugust 20181
2List of abbreviationsBREEAM – Building Research Establishment EnvironmentalAssessment MethodCHP – Community Health PartnershipsCHPI – Centre for Health and Public InterestCCG – Clinical Commissioning GroupDHSC – Department of Health and Social CareLIFT – Local Improvement Finance TrustLIFTCos – LIFT CompaniesMCP – Multi-specialty community providerNAO – National Audit OfficeNIHR – National Institute for Health ResearchPAC – Public Accounts CommitteePACS – Primary and acute care systemsPFI – Private Finance InitiativePF2 – Private Finance 2PPP – Public-private partnership3PD – Third-party developmentSTP – Sustainability and Transformation PartnershipVfM – Value for moneywww.theliftcouncil.org.uk
3ContentsIntroduction to the LIFT Council4Summary5A local partnership approach8Delivering new models of care10Private finance in NHS estates14Criticisms of the LIFT w.theliftcouncil.org.uk
4Introduction to the LIFT CouncilThe LIFT Council is the representative body for the non-public sector partners withinthe Local Improvement Financial Trust (LIFT) initiative. Following the introductionof the LIFT public private partnership model by the Department of Health in 2004,the Council was established in 2005 as a forum for discussion and a vehicle foraction as the clear industry voice of the LIFT community in dialogue both withpolitical and policy stakeholders and with the media. The Council is a thought leaderin debates around the provision of primary and community care premises in theNational Health Service in England.The LIFT Council’s eight members have significant experience of managing healthand social care facilities across England, with responsibility for nearly 300 buildings,representing over 80% of all LIFT buildings nationally. In addition to much-neededinvestment in these facilities, LIFT companies (LIFTCos) offer extensive strategicknowledge and expertise in local health care economies, the lack of which hasotherwise been recognised as a shortcoming preventing improvements to the NHSestate. LIFT has a proven track record of investing in primary care infrastructure tomove services out of hospitals and into community settings. Now is a crucial timefor NHS facilities, and LIFTCos are well placed to continue working with their publicsector partners to ensure that NHS properties are equipped to deliver the ambitionsof the Five Year Forward View.LIFT Council members are the private sector partners in LIFT, working closely withCommunity Health Partnerships: a wholly government owned subsidiary companyof the Department for Health and Social Care, which holds a 40% stake in allLIFTCos. The LIFT Council acknowledges the support given for this research by itsmembers:www.theliftcouncil.org.uk
5SummaryThe need for investment: a 21st century NHS estateThere is an urgent need for investment in the NHS estate across England to improvepatient experiences and ensure our healthcare infrastructure is fit to deliver newmodels of integrated care. The Naylor Review of NHS property and estates in 2017found that much of the estate is outdated with some healthcare buildings pre-datingthe formation of the NHS 70 years ago. The Government endorsed Sir RobertNaylor’s assessment, admitting that many buildings across acute, primary andcommunity care “would not meet the demands of a modern health service”. Themedical profession agrees, with seven in ten GPs viewing their practices as toosmall to offer additional services, and the British Medical Association calling for animmediate review of the primary care estate as part of its 2018 contractualnegotiations with the Government.The Department of Health and Social Care has stepped up its efforts to tackle thisissue, with the recent Budget and its formal response to the Naylor Review pledginga 10 billion investment package for NHS infrastructure over the next five years.However, the Government has made it clear that it will need to find funding from arange of sources, and call on the capacity and expertise of the private sector toenable the transformation needed to design and deliver a healthcare estate fit forthe 21st century.The benefits of LIFTLIFT companies have a track record of developing high quality primary andcommunity care buildings to suit local health needs. Evidence from several surveysduring the 15-year life-span of LIFT, demonstrates that the PPP model deliversbenefits including: A proven partnership approach to primary care estatesdevelopment, mandating close collaboration between public and privatesector stakeholders. Unlike other private procurement models, LIFTrequires that both public and private sector investors retain an equity sharein LIFT schemes, and evaluations of LIFT have found this approach leadsto effective risk transfer and alleviation of administrative burdens; interagency cooperation and co-location of previously separated bodies; andthe transfer of skills and experience between stakeholders, including animproved understanding of financial and strategic management issuesamong all parties.www.theliftcouncil.org.uk
6 A long-term community focused approach to local estateneeds, with contracts offering 25-year agreements backed by agovernment indemnity covenant. LIFT agreements offer well-balancedincentives to both private sector investors and the public sector equityholder Community Health Partnerships which is mandated to reinvestprofits into local estates and healthcare services. As part of its enduringcommitment, LIFT companies are in continuous dialogue with a wide rangeof NHS stakeholders, including through local estates forums, whilesimultaneously providing a range of partnering services to improve broaderstrategic estates planning and delivery.Delivering new care models for the NHSThe current nature of healthcare infrastructure presents a barrier to health and caretransformation demanded by the Five Year Forward View. The vision of NHSEngland Chief Executive, Simon Stevens, focused on creating new models of carethat would enable an efficient and effective integration of primary, acute, mentalhealth, social care and community services. LIFT can help to enable themodernisation of the estate by offering: A development model which has successfully shiftedadditional services into primary and community care. LIFTbuildings have, in many cases, provided access to treatments previouslyonly available in hospitals through award winning designs facilitating theintegration of services. LIFT supports the hubs model and implementationof multi-speciality community provider (MCP) and primary and acute caresystems (PACS) structures which bring together a wide range of healthcarestaff to better care for patients closer to their homes. A modern, flexible approach to development to ensure quality,which will be equally as important as models of development for a 21stcentury healthcare estate. LIFT has been specifically credited for raisingthe bar for quality in healthcare infrastructure development, by attractingnational construction and design teams and bringing more sophisticatedexpertise to the development of purpose built primary and community carebuildings. LIFTCos also seek to incorporate flexibility into designs to meetchanges required by the evolution of local estates and service planning,while maintaining premises to avoid the significant backlog maintenanceissues seen in other parts of the NHS.www.theliftcouncil.org.uk
7A role for private financeSir Robert Naylor has emphasised the need to embrace private investment in NHSestates development, particularly in primary care. The Government’s 5-yearprogramme of investment in healthcare infrastructure outlines an ask for over 3billion of capital from the private sector, though it is crucial this investment iscarefully scrutinised and does not recreate the problems of the past. Primary careestates development through LIFT will enable this as: LIFT differs significantly from traditional PFI arrangements. ThePPP model offers a value for money estates procurement option at lowercapital values than PFI builds, and unlike these controversial PFI deals,significant public sector shareholding in LIFT projects ensures local buy-infrom all stakeholders, as LIFTCos own, build, maintain and refurbish thepremises. While PFI is being reimagined as PF2 under stricter scrutiny ofvalue to the taxpayer, LIFT has been successful in delivering projects underset affordability caps, with every proposal forced to demonstrate value formoney prior to gaining approval. The LIFT Council supports the call for greater transparencyand more data on the value and utilisation of private capital inNHS estates development. Critics of LIFT sometimes cite project costs andrepayment rates as a reason not to utilise the model, but value for moneystandards through the appraisals process are designed to ensure goodoutcomes for patients and the taxpayer. A lack of information on cost, valueand utilisation of the estate reflects a broader issue facing the primary caresector in particular, for which detailed data is rarely produced or sharedpublicly. Public and private partners in LIFT are constantly innovating toreduce under-used building space and these efforts need to be supportedby a broader discussion on the many factors influencing utilisation of localhealthcare buildings.www.theliftcouncil.org.uk
8LIFT: a local partnership approachThe NHS LIFT model has provided a successful long-term approach towardsplanning, investment, development and maintenance of the primary care estateacross England since its introduction in 2004. A key feature of this success hasbeen the establishment of an effective partnership between public and privateshareholders in LIFT companies. Unlike in other private procurement models, LIFTrequires that both public and private sector investors retain an equity share in LIFTschemes, with the government owning a 40% stake in each LIFTCo throughCommunity Health Partnerships (CHP). A key lesson from the experience of LIFTover the past 15 years has been the positive impact the partnership approach canprovide, not only for the benefit of public and private sector officials closely involvedin LIFT projects, but also for the benefit of local healthcare communities as a whole.Progress through PPPsMultiple evaluations of the LIFT programme over the past decade have highlightedthe positive impact of its partnership approach to local healthcare estatesimprovement. The National Audit Office in 2005 found that LIFTCos weredemonstrating the ability “to build strong local partnerships with key stakeholders” 1and stated that “the structure of LIFT is designed to foster a spirit of partnership withstakeholders working together to achieve mutual goals”. The report also notedspecific benefits to the NHS, including risk transfer to the private sector whichenables “public sector healthcare professionals to focus on delivery of a goodquality service.”2In its 10-year progress report on LIFT – developed through independent research byAmion Consulting – CHP highlighted LIFT’s record of facilitating “broader linkagesand a more holistic approach to the delivery of health and community services”within localities. This is supported by “inter-agency co-operation” and the “colocation of previously separated bodies.”3Another independent investigation on the value of LIFT, carried out by the NationalInstitute for Health Research (NIHR) in 2010, repeatedly emphasised the benefitsof the partnership approach. The NIHR report “found evidence that LIFT hadcreated the organisational and institutional framework for effective partnershipNational Audit Office AO (2005), Innovation in the NHS: Local Improvement Finance Trust, page 3.NAO, page 10.3Amion Consulting (2014), The Impact of the Local Improvement Finance Trust Programme,Community Health Partnerships, page 6.12www.theliftcouncil.org.uk
9working within the NHS.”4 While interaction between various stakeholders workingwithin NHS frameworks is often accompanied by ‘cultural clash’, LIFT has beeneffective in promoting joint-working systems. NIHR stated that partners within LIFTprojects were “working together well” while “differences in culture were beingmanaged and accommodated as partnerships matured”.At an operational level, LIFT partnerships provide the opportunity for a transfer ofskills and experience between the public and private sectors. Working with privatesector LIFT investors and managers who specialise in healthcare estatesdevelopment has allowed public sector officials to gain “a significant understandingof strategic and financial management issues”5; develop strong commissioning andplanning skills6; and alleviate significant administrative burdens.7An enduring commitmentThe LIFT model provides the value of a stable, long-term partnership, with contractstypically offering 25-year agreements backed by a government indemnity covenant.The length of contractual arrangements between LIFT companies and local healtheconomies ensure a commitment to the community and its shifting healthcareneeds. The positive effect of this commitment is evident in research on LIFT, withthe NAO stating that contracts offer long-term “well-balanced”8 incentives to bothpublic and private sector partners. In its only review of the LIFT model in 2006, thePublic Accounts Committee endorsed the NAO’s finding that LIFT provides anenduring strategic approach to local health estates planning9, and this is furthersupported by NIHR’s assertion that “public private procurement and collaboration ismore effective within a framework of long-term contracting and repeat purchases.”10A key element of LIFT’s offer is in the strategic approach it provides for local healtheconomies or the regions covered by LIFT development. Both public and privatesector LIFT partners engage frequently with local NHS stakeholders, includingcommissioners, providers and local authorities, including through formalcollaborative working groups via local estates forums/groups. In the early stages ofLIFT this took place through the Strategic Partnering Boards 11 and in recent years,National Institute for Health Research (2010), The Role and Effectiveness of Public PrivatePartnerships (NHS LIFT) in the Development of Enhanced Primary Care Premises and Services , page4236.5NIHR (2010), page 238.6NIHR (2010), page 237.7NIHR (2010), page 238.8NAO (2010), page 26.9House of Commons Committee of Public Accounts (2006), NHS Local Improvement Finance Trusts,Forty-seventh report of Session 2005-06, page 23.10NIHR (2010), page 236.11Public Accounts Committee (2006), Public Accounts (2006), NHS Local Improvement FinanceTrusts, page4.www.theliftcouncil.org.uk
10some LIFTCos have become more closely involved in the development ofSustainability and Transformation Partnership (STP) estates plans, by providingcapability and capacity through ‘partnering services’. This includes the offer reprogrammes/reconfiguration and development across the STP footprint area. Thisservice has answered the call of the Naylor Review, highlighting the need for thehealth service to “improve capability and capacity to support national strategicplanning and local delivery.”12Community impact and reinvestmentWhile LIFTCos are for-profit enterprises, returns from investment flow both to publicand private sector partners. This delivers the clear benefit of enabling public-sectorreinvestment to meet local health needs. Indeed, the Government has recently reaffirmed its mandate that “all dividends received by CHP are re-invested exclusivelyinto the NHS.”13In addition, value for money for LIFT schemes needs to be securedat business case approval on the terms of both public and private sector partners,providing a level of transparency and oversight not consistently seen through otherprocurement routes. Finally, LIFT developments have often made a positive impacton more deprived communities. In 2014, Amion found that close to 90% of LIFTprojects are situated in areas with above average health needs. 14 The buildings arealso typically in areas where there are few other employers and will often providethe main source of local employment.15Delivering new models of careThe NHS in England is undergoing a step change in its approach to providing care.Simon Stevens’ Five Year Forward View strategy, first published in 2014, was anoverdue attempt to modernise the delivery of services by better integrating hospital,primary, community, mental health and social care to ensure better outcomes forpatients across the country. More recently, this national strategy has been takenforward through the development of STPs and the amalgamation of serviceproviders through accountable care, though it is clear that the pace of change needsto increase. There are very few stakeholders across the NHS who would argueagainst the need to bring services together ‘under one roof’, but the practicalities ofproviding that physical environment are a challenge. Estates transformation hasbeen identified – both at a national and local level – as a key enabler of integrationNaylor, Sir Robert (2017), NHS property and estates: why the estate matters for patients, page 4.Hansard (2018). Answer to parliamentary written question, Stephen Barclay MP, 8 February, 2018.CHP (2014), page 5.15CHP (2014), page 11.121314www.theliftcouncil.org.uk
11through new care models, with the development of new buildings providing theopportunity to shift care into the community. LIFT has a key part to play in thistransformation, as providers and commissioners across the country seek to makesignificant changes to their health and care infrastructure.Developing the 21st century estateThere is an acknowledgement across the NHS that the current state of England’shealthcare infrastructure presents an obstacle to transformation. In its response tothe Naylor Review, the Department ofHealth and Social Care agreed with SirRobert’s findings, admitting that “some ofthe estate is old, in parts even older thanthe NHS itself”, contending that thesebuildings “would not meet the demandsof a modern health service”.16 The nonparty think-tank Reform published areview of the primary care estate inJanuary2018which“infrastructure is aaddedbarrier”17thatto thetransformation of health and care services, noting the British Medical Association’sfinding that seven in ten general practitioners regard their buildings as too small todeliver the additional services demanded by the Five Year Forward View.18LIFT provides a solution to the ‘state of the estate’, offering a development modelwhich has consistently designed buildings to provide more than just traditionalprimary care services. NIHR found evidence that “LIFT projects have extendedprimary care delivery, providing services, previously only available in hospital”19 andDHSC has endorsed the expansion of LIFT for this purpose, stating that the modelis a “critical part of (its) primary care strategy” given its aim to “integrate health,community and local authority services like gyms and libraries.”20Quality will be equally as important as procurement type in the development of a21st century healthcare estate. Senior NHS officials have told the LIFT Council thatpremises designed through LIFT are considered to be of a very high quality. All newhealth buildings in the UK are required to meet a high sustainability standard underDepartment of Health and Social Care (2018), The Government Response to the Naylor Review,page 5.17Reform (2018), A design diagnosis: reinvigorating the primary care estate, page 2.18Reform (2018), page 3.19NIHR (2014), page 49.20DHSC (2018) Naylor Review response, page 16.16www.theliftcouncil.org.uk
12the Building Research Establishment Environmental Assessment Method(BREEAM)21, but LIFT h
NAO – National Audit Office NIHR – National Institute for Health Research PAC – Public Accounts Committee PACS – Primary and acute care systems PFI – Private Finance Initiative PF2 – Private Finance 2 PPP – Public-private partnership 3PD – Third-party development
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