Local Improvement Finance Trust Research Articles

Public–private joint ventures in the healthcare sector: enlarging the shadow of the future through social and economic incentives

PurposePublic–private joint ventures (PPJVs) have a stronger partnership element than standard public–private partnerships (PPPs) but PPJVs are under-researched despite this important partnership element. This article derives knowledge of incentives and barriers to goal alignment in healthcare PPJVs.Design/methodology/approachAn in-depth case study of the UK’s Local Improvement Finance Trust (LIFT) model including three PPJVs and 34 individual projects was conducted.FindingsThe main economic incentives are future opportunities creating a strong shadow of the future. This is supplemented by social incentives such as the ability to have a social impact. Enlarging the shadow of the future can encourage both parties to think long-term, avoiding short-term opportunism.Practical implicationsPPJV is a promising model for partnership. However, complexity through fragmented public sector partners and the financial structure can create barriers for goal alignment.Originality/valueThis study challenges earlier research studies based on PPJV by providing evidence that the long-term nature of PPJV, especially the potential of new projects, enables the public sector to get more engagement from the private sector.

Does the United Kingdom’s Local Improvement Finance Trust (LIFT) Scheme for Primary Health Care Enhance Partnership Working?

This article draws on a qualitative case study comparing two U.K. primary health care schemes which were entered into as part of the Local Improvement Finance Trust (LIFT) policy. LIFT takes the form of a social infrastructure Public Private Partnership (PPP) where public procurers and private suppliers work together in active long-term partnering agreements to deliver local primary health care facilities. The organizational structure is that of a joint venture company which is jointly owned by public and private partners, with the expectation that by having both the public and private sector represented on the company board partnership working between the two sectors is enhanced. The two schemes studied delivered contrasting results. One scheme showed how the private sector dominated the board, making partnership working difficult to achieve in the context of directors following their fiduciary role to maximize profits for shareholders. However, the findings from the second scheme showed that partnership working and LIFT success may be dependent on trust, general business ethos, and key personalities working together. Policy makers should therefore pay attention to not only the organizational structures, but also how the private sector controls and governance are exercised to benefit all stakeholders.

Public-private partnerships to improve primary healthcare surgeries: clarifying assumptions about the role of private provider activities.

PPPs were developed to improve the quality of care and patient satisfaction. However, evidence of their effectiveness in delivering health benefits is limited. A qualitative study design was employed. A total of 25 interviews with public sector staff (n=23) and private sector managers (n=2) were conducted to understand their interpretations of assumptions in the activities of private investors and service contractors participating in Local Improvement Finance Trust (LIFT) partnerships. Realist evaluation principles were applied in the data analysis to interpret the findings. Six thematic areas of assumed health benefits were identified: (i) quality improvement; (ii) improved risk management; (iii) reduced procurement costs; (iv) increased efficiency; (v) community involvement; and (vi) sustainable investment. Primary Care Trusts that chose to procure their surgeries through LIFT were expected to support its implementation by providing an environment conducive for the private participants to achieve these benefits. Private participant activities were found to be based on a range of explicit and tacit assumptions perceived helpful in achieving government objectives for LIFT. The success of PPPs depended upon private participants' (i) capacity to assess how PPP assumptions added value to their activities, (ii) effectiveness in interpreting assumptions in their expected activities, and (iii) preparedness to align their business principles to government objectives for PPPs. They risked missing some of the expected benefits because of some factors constraining realization of the assumptions. The ways in which private participants preferred to carry out their activities also influenced the extent to which expected benefits were achieved. Giving more discretion to public than private participants over critical decisions may help in ensuring that assumptions in PPP activities result in outcomes that match the anticipated health benefits.

The role of structure in manipulating PPP accountability

PurposeThe purpose of this paper is to examine the accounting and governance of public private partnerships (PPPs) that are structured as joint venture partnerships. Drawing on Giddens’ structuration theory, the paper examines how human agents interact with these joint venture structures and analyses the effects on financial disclosures and public accountability for taxpayers’ investments.Design/methodology/approachThe authors adopt a cross-case analysis to investigate two such PPP schemes, which form part of the UK’s programme of investment in primary healthcare, known as the Local Improvement Finance Trust (LIFT) policy. The authors employ a combination of interviews and analysis of financial statements and publicly available official documents.FindingsThe corporate structure of these LIFT schemes is very complicated so that the financial accounting is opaque. The implication is that the joint venture mechanism cannot be relied upon to deliver transparency of reporting. The paper argues that the LIFT structures are deliberately constructed by human agents to act as barriers to transparency about public expenditure.Practical implicationsThe financial reporting undermines public accountability and transparency as both are necessarily restricted. Policy makers should pay attention to not only the private sector technologies but also the manner in which structures are used to reduce transparency and consequently undermine public accountability.Originality/valueThe paper provides detailed analysis from the perspective of structuration theory to show how human agents use structures to impact on financial reporting and public accountability.

Public-private partnerships and efficiency in public procurement of primary healthcare infrastructure: a qualitative research in the NHS UK

There is growing interest in the contribution of public-private partnerships (PPPs) bridging the shortage of financial resources and management expertise in developing public healthcare infrastructure. However, few studies have evidenced PPPs’ ability in increasing efficiency in public procurement of primary healthcare infrastructure. The aim of this study was to assess to what extent PPPs would increase efficiency in public procurement of primary healthcare facilities. A qualitative analysis, adopting a realistic research evaluation method, used data collected from a purposive sample of public (n = 23) and private sector staff (n = 2) directly involved in the UK National Health Service Local Improvement Finance Trust (LIFT). We find a positive association of LIFT helping to bridge public sector capital shortages for developing primary care surgeries. LIFT is negatively associated with inefficient procurement because it borrows finance from private banks, leaving public agencies paying high interest rates. The study shows that some contextual factors and mechanisms in LIFT play a major part in obstructing public staff from increasing procurement efficiency. PPP’s ability to increase efficiency may be determined by contextual factors and mechanisms that restrict discretion over critical decisions by frontline public sector staff. Developing their capacity in monitoring PPP activities may make partnerships more efficient.

Managing cultural diversity in healthcare partnerships: the case of LIFT

The National Health Service (NHS) Local Improvement Finance Trust (LIFT) programme was launched in 2001 as an innovative public-private partnership to address the historical under-investment in local primary care facilities in England. The organisations from the public and private sector that comprise a local LIFT partnership each have their own distinctive norms of behaviour and acceptable working practices - ultimately different organisational cultures. The purpose of this article is to assess the role of organisational culture in facilitating (or impeding) LIFT partnerships and to contribute to an understanding of how cultural diversity in public-private partnerships is managed at the local level. The approach taken was qualitative case studies, with data gathering comprising interviews and a review of background documentation in three LIFT companies purposefully sampled to represent a range of background factors. Elite interviews were also conducted with senior policy makers responsible for implementing LIFT policy at the national level. Interpreting the data against a conceptual framework designed to assess approaches to managing strategic alliances, the authors identified a number of key differences in the values, working practices and cultures in public and private organisations that influenced the quality of joint working. On the whole, however, partners in the three LIFT companies appeared to be working well together, with neither side dominating the development of strategy. Differences in culture were being managed and accommodated as partnerships matured. As LIFT develops and becomes the primary source of investment for managing, developing and channelling funding into regenerating the primary care infrastructure, further longitudinal work might examine how ongoing partnerships are working, and how changes in the cultures of public and private partners impact upon wider relationships within local health economies and shape the delivery of patient care. To the authors' knowledge this is the first study of the role of culture in mediating LIFT partnerships and the findings add to the evidence on public-private partnerships in the NHS.

Evaluation of key practices under the Local Improvement Finance Trust (LIFT) initiative for UK healthcare facilities

PurposeThis paper aims to examine whether the UK Local Improvement Finance Trust (LIFT) procurement strategy supports the delivery of facilities for improved primary and social care services that meet local needs while providing value for money.Design/methodology/approachThe research employed a qualitative approach (case study), involving semi‐structured interviews with senior managers involved in three LIFT schemes.FindingsThe investigations revealed significant differences in the maturity levels of the schemes evaluated in terms of systems, processes and structures used in the planning and implementation of the schemes. Although there is potential for further improvements, the pattern of progress made generally confirmed an evolving system, with considerable evidence of performance improvement from project‐to‐project.Research limitations/implicationsThis evaluation involved only three LIFT schemes and thus utmost caution should be taken in generalising the results. In addition, the evaluations were limited to project management perspectives related to the built environment component and did not delve into clinical aspects.Practical implicationsThe paper identified both good practices (that could be transferred across schemes and between projects) and poor practices (that require improvements) from the schemes evaluated.Originality/valueAlthough potential ways for securing further long‐term improvements and sustained value for money were highlighted, this paper provides prima facie evidence that the LIFT initiative is delivering the expected economies of scale in providing modern facilities for the provision of integrated primary and social care services.

‘A potential fifth column’: conflicts and struggles for control in the context of local NHS privatization

This article uses case study data to discuss how a new procurement policy (Local Improvement Finance Trust, or LIFT) in English primary care may affect general practitioners' control over their work. LIFT, a series of 51 public-private partnerships, will enable over the medium term a shift towards the corporate ownership of surgeries and the creation of polyclinics or 'onestop-shops'. In this article, I explore the struggles over work autonomy and control within these new LIFT structures, as expressed by clinicians and managers in meetings and in research interviews. More generally, I consider how the findings inform debates over the changing position of professionals within increasingly financialized 'local health economies'.

Managing risk and regulation within new local ‘health economies’: The case of NHS LIFT (Local Improvement Finance Trust)

This paper analyses NHS Local Improvement Finance Trust (LIFT), a relatively new policy that shifts UK primary care premises into corporate ownership. LIFT is a more radical version of the Private Finance Initiative (PFI), and may indicate the future direction of neoliberal welfare services. Like PFI, LIFT foregrounds issues of risk and regulation, enabling their reconceptualization. This echoes certain themes present in the sociology of risk, including the idea that the welfare state has created and amplified, rather than managed, risk. Under LIFT, risks are constructed as (a) primarily economic and (b) primarily from the point of view of the large commercial organizations involved. Evidence presented here depicts banks as risk averse, challenging assumptions that private firms display risk-taking behaviour. The prioritization of economic risks is shown to amplify social risks, and to produce threats to social regulation. These threats are amplified by unequal power relationships within these new ‘local health economies.’ It is argued that LIFT is undermining the NHS's social embeddedness in local areas, partly by threatening the position of general practitioners and other small business or community organizations. Ultimately, the model is likely to generate new social and economic risks currently obscured by official discourse around LIFT.

NHS LIFT and the new shape of neoliberal welfare

The NHS LIFT (local improvement finance trust) programme is a new form of privatisation of UK primary care, based on the private finance initiative but going beyond it in important ways. It covers half of all English primary care trusts, and the approach has also been extended into education (the Building Schools for the Future’ programme). The LIFT model embeds multinational capital and corporate forms into UK primary care and affects both staff and services, but challenges to it have been patchy and low-key. There is a need to theorise what this new development means for public services, and to examine the potential for resistance to it.

Flexible regulation: the birth of a qualitative audit society?

This article discusses the emergence of qualitative techniques of audit. In particular, it focuses on the auditing of the UK policy National Health Service Local Improvement Finance Trust (NHS LIFT), a policy that shifts provision of primary care premises to the corporate sector. In this case, far from qualitative audit representing a pluralist approach it actually signifies the regulatory capture of the National Audit Office (NAO) by powerful private and public sector interests. The article considers how this shift in regulatory techniques – including the adoption of qualitative techniques including snowball sampling, case studies and interviewing – is linked to a change in the auditor's role. Qualitative research can be appropriated and re-shaped by powerful groups.

Closed policy networks, broken chains of communication and the stories behind an ‘entrepreneurial policy’: The case of NHS Local Improvement Finance Trust (NHS LIFT)

This article draws on original case study research to develop more general conclusions about policy-making processes under New Labour. I discuss the Local Improvement Finance Trust (LIFT) as an exemplar of new trends in contemporary capitalist welfare regimes, and I compare some of the enterprise rhetoric surrounding and justifying LIFT to the experiences of National Health Service managers and clinicians in my case study. I consider why many of the voices that I studied appear to remain unheard outside private interviews and meetings, and conclude that changes in the public sector are helping to create closed networks that are unresponsive to concerns expressed ‘on the ground’. Finally, I consider some implications of my data for the future of neo-liberal welfare policies.

LIFT: 21st century health care centres in the United Kingdom

PurposeTo examine the processes used to procure and develop new primary health care premises in the United Kingdom and in particular the use of the private finance initiative and related methods.Design/methodology/approachAn in‐depth study of two local improvement finance trust schemes to procure new primary health care premises. These are contrasted against the ad‐hoc arrangements for the traditional procurement of general practice doctor's surgery premises. Interviews were undertaken with key participants on both sides of the negotiations.FindingsThe process can be an unequal struggle between large consortia and small, inexperienced clients that may result in a wasted opportunity to obtain the optimum design and price.Research limitations/implicationsThe research is limited to early use of the local improvement finance trust process and procedures; client bodies, such as primary care trusts, may benefit from the experience of earlier projects. The method of procurement will evolve and be refined and will become more widely used, not only for health but also in the education sector. Further examination of the procurement of education buildings using similar methods would be beneficial.Originality/valueThis method of procuring buildings is relatively new, and therefore, largely untried.