英國醫療服務PPP:Derant Valley醫院案例分析(中英文對照)

原標題：英國醫療服務PPP：Derant Valley醫院案例分析(中英文對照)

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摘自歐亞PPP聯絡網編著，王守清主譯．《歐亞基礎設施建設公私合作(PPP)：案例分析》(中英文對照)，第230-247頁，北方聯合出版傳媒集團，2010年8月

Case Study - Derant Valley Hospital UK PPP for Health Care Provision / 案例 – 英國醫療服務PPP：Derant Valley醫院

by Ce Li, edited by Dr. A.Merna and Mr. D. K. Anderson, University of Manchester

曼徹斯特大學Ce Li；A. Mern 博士和D.K. Anderson 編輯；清華大學趙國富和王守清譯

1.1 Introduction / 引言

This case study describes the processes,risks and financial aspects associated with the first PPP hospital built in the United Kingdom.Since this hospital’s inception over 34 more hospitals and 19 other health schemes have been procured under PFI in the United Kingdom, many of these hospitals have followed this model although some have used the private sectoras well as the public sector to provide health care.

The Derant Valley Hospitalis a state of the art hospital built to a maximum three storey building heightand catering for a variety of medical conditions and the necessary facilities and treatment.

本案例介紹了英國建設的第一個醫院PPP項目的過程、風險和財務方面的信息。自該醫院興建以來，英國已有超過34個醫院和其它19個醫療計劃是採用PFI模式獲得的，儘管有一些醫院已由私營部門和公共部門共同來提供醫療服務，其中許多醫院仍然沿用這一模式。

Derant Valley醫院是一所現代化的醫院，共三層，具備各種醫療條件、配備必要的設施並提供必要的醫療服務。

1.2 Project History / 項目歷史

Derant Valley Hospital project was the UK's flagship PFI hospital development. The overall planning and development allowedfor change and growth throughout the hospital. With the number of older people increasing, there are more than 200,000 patients needing to be cared for every year in Dartford. The three old and outdated hospitals, Joyce Green, West Hill and Gravesend and North Kent in Gravesend, could not meet the required demand or service necessary.

Derant Valley醫院項目是英國PFI醫院發展的標誌性項目。整體計劃和發展要求醫院進行變化和發展。隨著老年人的不斷增加，在達塔福德(Dartford)每年有近200000病人需要護理。格雷夫斯(Gravesend)的三個陳舊和過時醫院——JoyceGreen、West Hill and Gravesend和North Kent，已經不能滿足需求或提供必要的服務。

In1995, Dartford & Gravesend NHS Trust (DGNHST) considered providing a new,advanced hospital to replace the old ones in order to provide a better healthcare service. A feasibility study was undertaken in 1995 by DGNHST, which clearly indicated that the PFI/PPP route was a realistic one. It should benoted that this project would not have been sanctioned if a PFI/PPP procurement strategy had not been adopted. It was in fact the only deal in town. The project was advertised in the Official Journal of the European Community (OJEC) later that year.

1995年，達塔福德和格雷夫斯國家衛生部信託基金會(DGNHST)考慮興建一座新的、先進的醫院來取代舊的醫院以提供更好的醫療服務。該基金會於1995年進行了可行性研究，明確指出PFI/PPP模式是一個現實的方案。需要注意的是，如果沒有採用PFI/PPP採購策略，該項目可能不會獲得批准。事實上，該項目是該城鎮唯一的PFI/PPP項目。該項目同年晚些時候在歐盟官方雜誌(OJEC)上發布了公告。

Abid procedure typically has three routes:

§ open procedure

§ restricted procedure

§ negotiation procedure

招標程序通常有三種方式：

§ 公開招標

§ 限制性招標

§ 協議招標

However, the open procedure isnot suitable for PFI projects, as the cost of bidding is too high to encouragea large number of competitive bidders and a negotiated contract was notconsidered to comply with UK and EU requirements. DGNHST therefore employed a restricted procedure wherebidders expressed an interest with some invited to pre-qualify. A thorough andclear specification set out the criteria that bidders had to follow. The philosophy behind the bid was to give healthcare staff the best environment that would allow them to spend more time on patient care. After six months assessment and approval by the Department of Health, of the full business case prepared by the Trust, there emerged a preferred submission, that being The Hospital Company (Dareath Ltd.) that is a consortium made up from Carillion Construction and Carilllon Services.

然而，公開招標方式不適用於PFI項目，因為投標費用非常高以至於不能吸引大量投標人；協議招標也不適用，因為與英國和歐盟的要求不符。因此，基金會採用了限制性招標方式，邀請有興趣的部分投標人參與資格預審。全面和清晰的說明書明確了投標人所必須遵照的標準。最基本的要求就是為醫護人員提供最佳的環境以利於他們用更多的時間用來照顧病人。衛生部對基金會編制的整個商務方案進行了六個月的評估和批准，由科瑞林(Carillion)建設公司和科瑞林服務公司組成的聯營體德萊斯有限公司(Dareath Ltd.)脫穎而出成為首選中標者。

DareathLtd. was awarded a contract to design, build, finance and operate (DBFO) a new 400 bed hospital at Derant Park to replace the threeold and outdated hospitals. Carillion Construction Company had responsibilityfor the design and construction of the new hospital. The subsequent provisionof support service is provided by Carillion Service Ltd. and its subcontractors.DGNHST leases the hospital building, purchases ancillary services, such as catering,cleaning and security from Dareath Ltd. The NHS, however, employs medical and para-medical staff drawn from the public sector who work alongside the Facilities Management company drawn from the private sector.

德萊斯有限公司獲得了在Derant公園設計、建造、融資和運營(DBFO)一個含400個床位的新醫院以取代三個過時舊醫院的合同。科瑞林建設公司負責該新醫院的設計和建設，而科瑞林服務公司及其分包商負責提供相應的服務支持。項目建成後，基金會(DGNHST)向德萊斯有限公司租用醫院建築，購買配套服務，如餐飲、保潔和保安服務。而國家衛生部(NHS)從公共部門抽調聘用醫生和輔助醫務人員與來自私營機構的設施管理公司一起工作。

Opened in September 2000, Darent Valley Hospital has 419 beds and provides in-patient and out-patient care, drawing on an annual budget of around £80 million starting in 2001. (K&M 2004). The hospital employs more than 1500 medical and non-medical staff and has contract term of 28 years of operation and maintenance. Financial difficulties in terms of meeting repayments have necessitated the Trust negotiating to extend the service contract for a further 5 years.

DarentValley醫院於2000年9月開業，共有419個床位，可為住院病人和非住院病人提供醫療護理，從2001年起，每年的預算約8千萬英鎊(K&M2004)。該醫院僱傭了1500名醫生和輔助醫務人員，籤訂了28年的運營和服務合同。還本付息的財務困難使該基金會需要進行延長5年服務合同的談判。

1.3 Project Objectives / 項目的目標

The main objectives of this project were to create a state of the art medical facility which would provide value for money and provide much needed treatment to the public in the North Kent area. If successful, the PPP arrangement would then form a model for future hospital projects.

該項目的主要目標是建設一個現代化的醫療設施，實現物有所值，為北肯特地區的公眾提供所需的醫療服務。如果成功，PPP模式將會成為未來醫院項目的典範。

A further objective was to ensure that the stakeholders to the project, both internal and external were all involved in the decision making process as the project developed.

進一步的目標就是確保項目的干係人，包括內部和外部的，都能隨著項目的發展參與項目的決策過程。

As a flagship project both the public and private sector partners were keen to ensure a successful project based on a carefully researched performance specification based on extensive consultation with all stakeholders.

作為標誌性的項目，公共部門和私營部門參與方均渴望利用在廣泛諮詢所有干係人基礎上仔細研究確定的績效標準來保證項目成功。

1.4 Project Partners / 項目參與方

Figure1 illustrates the project structure and the financial flow for the project.

圖1表示了該項目的結構和資金流。

Figure 1: Project structureand Financial Flow, (Carillion 2004)

圖1：項目結構和資金流

Project stakeholders』 interest can be positively or negatively affected by any project. In recent years,public dissatisfaction with public hospital projects applying a conventional approach to health care has increased. Stakeholder groups felt left out and the hospital Trust were under-informed. Hospital staff that were directly affected were not involved or were only involved to a limited extent and often late in the project. The lack of stakeholders』 involvement tends to generate a situation where those groups involved in the project under-perform. Under this PPP arrangement both public and private sector stakeholders were encouraged to actively involve themselves from the start of the project. "Satisfy Stakeholders!" is Derant Valley Hospital project's mantra, an objective that has been met.

項目干係人的利益可受到來自任何項目的正面或負面影響。近幾年，公眾對應用傳統方式提供的公共醫院項目越來越不滿。干係人感覺自己被忽略了，醫院基金會沒有獲得足夠的信息。受影響的醫院員工沒有參與或只是有限或滯後參與項目。干係人參與的缺乏導致參與項目的這些團體表現不佳。而在此PPP模式下，公共部門和私營部門都獲鼓勵，從項目開始就積極參與項目。「使干係人滿意！」是DerantValley醫院項目的口號，也是已實現的目標。

To succeed, it is not enough to deliver on the Trust's demand, it is also critical to understand who the potential project stakeholders are and the potential roles that they will play in the development of the project, and meet all stakeholder expectations.Identifying stakeholders was a primary task because all the important decisions during the initiation, planning and execution stages of the project were made by these stakeholders. Under the Derant Valley Hospital project, stakeholders were not only those in the project team, the functional management, the sponsor, and hospital staff, but also include anyone who is impacted by its results. Table 1 illustrates the internal and external stakeholders to this project.

Internal Stakeholders	External Stakeholders
Demand side	Supply side	Private	Public
Dartford & Gravesend NHS Trust Funders and investors Project teams	Carillon Group Sub contractor	Hospital staff D & G citizens	Regulatory agencies other relative government departments NHS

為了取得成功，僅僅滿足該基金會的要求是不夠的，同樣關鍵的是要了解誰是潛在的項目干係人和他們在項目發展過程中所扮演的角色，以及滿足所有干係人的期望。識別干係人是第一步工作，因為在項目啟動、規劃和實施階段所有重要的決定都是由這些干係人做出的。在DerantValley醫院項目中，干係人不僅僅是項目團隊中的人(如職能管理、主辦人、醫院員工)，還包括任何受到項目結果影響的人。表1列出了該項目的內部和外部干係人。

Table1: Stakeholders of the Darent Valley Hospital Project

表1：Darent Valley醫院項目的干係人

內部干係人	外部干係人
需求方	供給方	私營部門	公共部門
D&G地區基金會 基金持有者與投資者 項目團隊	Carillon 集團 分包商	醫院員工 D&G 地區居民	監管機構 其他相關政府部門 國家衛生部

1.5 Project Scope / 項目範圍

The project is located in the Dartford and Gravesend area of North Kent in the south east of England and was designed to accommodate those services previously provided by 3 old hospitals. The new hospital provides numerous medical care facilities for both in and out patients. The hospital is financed, built and operated by the private sector with health care provided by the public sector. At the end of the operation and maintenance term contract the facility will be transferred to the public sector who will have the opportunity to either manage the asset themselves or offer through a competitive tender a further Facilities Management contract for a specified time period.

該項目位於英格蘭東南部NorthKent的Dartford和Gravesend地區，目的是提供原先由三個舊醫院提供的醫療服務。新醫院提供多種住院和非住院醫療服務。項目的融資、建造和運營由私營部門負責，而醫療服務則由公共部門負責。在運營和維護合同期屆滿時項目設施將移交給公共部門，後者有權決定自己管理該資產，或通過競爭性招標發包一定期限的設施管理合同。

1.6 Legislation Issues / 法律事項

Nospecial local, regional or national enabling or statutory legislation was needed as PFI/PPP projects have been an integral and major part of infrastructure development, operation and maintenance in the UK for over twenty years. Both alegislative framework and a growing case law history were in place.

不需要任何特殊的地方、區域或國家層面的法規立法，因為PFI/PPP項目在英國成為公共基礎設施發展、運營和維護的重要組成部分，已有20多年的歷史，已經有了相應的法律框架和不斷增加的判例記錄。

1.7 Concession Agreements / 特許權協議

Figure2 illustrates the payment mechanism for this project.

圖2說明了該項目的支付機制。

Figure 2: Payment Mechanism

圖2：支付機制

The delivery performance of the service proposed is linked with the payment mechanism, which can provide value for money for the public. In this payment mechanism, the total payment comprises an availability payment and a performance related payment. Certain quality criteria were established and if the operator fails to achieve the specific objective criteria, there will be a reduction in the performance related payment.

既定服務提供的績效與支付機制相關聯，可為公眾提供資金的價值（物有所值）。在該支付機制中，總支付由可用性支付和與績效關聯的支付組成。制定了一定的質量標準，如果運營商未能達到相應的標準，與績效關聯的支付將被扣減。

1.8 Financial Arrangements / 融資安排

1.8.1 Initial Arrangements / 初始安排

The total financing requirement for the project was £115 million. The financial instruments employed in the project were debt and equity at Financial Closure, followed by a debt/bond swap and sale of equity as part of the project refinancing.

該項目總投資1億1千5百萬英鎊，融資完成時本項目採用的融資工具是貸款和資本金，此後則有債/券轉換和資本金出售作為再融資的一部分。

The SPV initially borrowed the majority of the money needed for the project with the total funding requirement of the project provided in a ratio of approximately 88:12 of non-recourse debtto equity (£101 million long term debt and £14 million equity).

特殊目的公司(即項目公司)最初借貸了項目所需總資金的絕大部分，其中無追索貸款和資本金的比例約為88:12(即1.01億英鎊的長期貸款和0.14億的資本金)。

Funding for the Derant Valley hospital project was obtained in the form of long-term bank loans (some of which were replaced by bonds during the operation period) without recourse to the shareholders and were secured on the assets of the SPV. The lender recognised the risk of the SPV defaulting on its loans and thus required shareholders in the SPV to place some of the capital at risk as an incentive to perform in the form of equity. £14 million equity was issued in a subion of shares, which was a loan from the shareholders of the SPV. Equity investment carries a higher risk than non-recourse debt as it pays out a return only afterall other liabilities of the SPV have been discharged in full.

Derant Valley醫院項目的資金主要通過銀行長期貸款的方式獲得(其中部分在運營階段被債券所替換)，且對項目股東無追索，僅以項目公司的資產作擔保。隨後放貸方認識到項目公司不能還本付息的風險，於是要求項目公司股東以資本金的形式投入部分承擔風險的資金作為一種激勵措施。發行了0.14億英鎊的資本金作為配股，是項目公司股東的出借款。資本金投資比無追索貸款承擔更高的風險，因為只有當項目公司所有的負債都還清之後，股東才能獲得回報。

The principal bank advising the Trust was Lloyds TSB, the financial adviser was KPMG and the legal adviser was Nabarro Nathanson. Debt was raised from Deutsche Morgan Grenfell, UBK Rabobank and 11 other banks. Financial Closure for this project was 30th July 1997.Construction on the project started in September 1997 and it became operationalon 11th September 2000. The 3 year construction period was to programme.

為該基金會提供諮詢的首席銀行是Lloyds TSB，融資顧問是畢馬威會計師事務所，法律顧問為Nabarro Nathanson。貸款來自於德意志摩根建富(DeutscheMorgan Grenfell)、UBK Rabobank 和11家其他銀行。該項目的融資完成時間為1997年7月30日，項目建設於1997年9月開始，於2000年9月11日投入運營，三年建設期符合計劃。

1.9 Refinancing / 再融資

In 2001, the SPV of the Derant Valley Hospital project, which was £101 million in debt, refinanced part of the debt by swapping £8 million of senior debt into a bond. This resulted in a reduction in debt payment allowing the SPV to better manage its debt and improve cash flow. The fixed coupon bondwould only pay bi-annual coupons over a period of 10 years but would not payany principal until the end of that period.

2001年，Derant Valley醫院項目的特殊目的公司(負債1.01億英鎊)，通過將800萬英鎊的高級債務轉換為債券進行了再融資。這樣減少了還債負擔，從而使項目公司能更好地管理債務和改善現金流。固定息票債券只需在10年期內每年付息兩次，而不必在該期間償還本金。

In November 2003, the SPV sold £4.1 million equity in the Derant Valley Hospital PPP concession to Barclays UKInfrastructure Fund. In addition to the £5.2 million that the SPV received forits equity interest, the sale crystallised as profit the £11.2 million of cash received when this PPP concession was refinanced in March 2003. The promoter’s proceeds from the sale and refinancing are therefore some £16.4 million, fourtimes the value of the original investment in this project of £4.1 million. In accordance with HM Treasury Guidelines, the refinancing gain was shared with the Dartford and Gravesham NHS Trust, which received some £10 million mainly in the form of lower annual payments to the SPV. Even though the refinancing gain was shared with the public partnercritics of the PFI/PPP procurement route consider the private sector is making too much profit from such arrangements.

2003年11月，項目公司將Derant Valley醫院PPP特許權中的410萬英鎊的資本金出售給英國巴克萊基礎設施基金公司。除了項目公司獲得資本金收益520萬英鎊外，該項出售在2003年3月的PPP特許權再融資時沉澱為0.112億英鎊的現金利潤。因此，主辦人通過出售權益和再融資共獲得0.164億英鎊的進項，是項目最初投資額0.041億英鎊的4倍。根據英國財政部的指南，再融資的收益應該與該基金會分享，後者獲得約1千萬英鎊，主要以減少給項目公司的年度支付額的形式。儘管再融資收益與公共部門分享了，PFI/PPP採購模式的批評者認為，私營部門從這種安排中獲得了太多的利潤。

1.10 Incentives / 激勵措施

Incentives,as discussed in Section 7 above are primarily team based incentives, similar to those adopted in PFI prison projects. The team based approach seeks to raise standards over and above those identified in the performance specification.Team based performance schemes have been adopted in a number of PPP hospital projects and seek to exploit both individual and group standards with rewards,in terms of bonus payments typically being paid for efficiency gains, cost savings and quality of care. These soft measures are integrated into theoperation of the hospital where similar schemes in terms of cost savings in Facilities Management are monitored by independent assessors.

正如前面第7節所討論的，激勵措施主要是基於團隊的激勵，類似於那些採用PFI的監獄項目。基於團隊的方法力圖提高標準以達到並超過績效規範中的標準。基於團隊績效方案已在一些PPP醫院項目中採用，並力圖建立個人和團體標準和相應的回報，典型的回報形式有基於效率提高、成本節約和服務質量的的獎勵報酬。這些軟措施融合於醫院的運營之中，設施管理中採取的節約成本的類似方式是由獨立的評審員監控的。

1.11 Discussion / 討論

Risk Analysis:

The risks associated with concession projects are far greater than those considered under traditional forms of contract, since the revenues paid by the principle must be sufficient to pay for construction, operation and maintenance, and finance. The uncertainties such as client’s affordability, the cost of finance,the length of concession periods, the effects of commercial, political, legal and environment factors must be considered by promoter organizations. Table 2 illustrates a number of areas of risks that impacted on the Derant Valley Hospital project.

風險分析

特許權項目的相關風險要比採用傳統合同方式項目的風險大，因為投資所獲收益原則上必須足以支付建造、運營、維護和融資成本。項目主辦人必須充分考慮項目的不確定性，如客戶的支付能力、融資成本、特許期長度、商業、政治、法律和環境的影響等。表2表明了影響DerantValley醫院項目的風險。

Table 2: The PPP Risk Spectrum

表2: PPP風險

Design and Construction Risks:

Time and cost overruns, environmental issues, and inherent liabilities/defects were considered as major risks in this project. Hospitals need to plan with greater regard to community service and the possibility of risks associated with demand and destructive technology.These risks impacted on the design of the project.

設計和建造風險

工期延長和成本超支、環境問題、內在的責任/缺陷被認為是該項目的主要風險。醫院項目在制定計劃時需充分考慮社區服務以及與需求和破損有關的風險。這些風險影響到項目的設計。

Residual Risk:

The concession contract is over a period of 32 years, of which 28 years are operation and maintenance. The SPV faces quality issues with respect to transferring facilities, with a lower quality standard, particularly equipment at the transfer stage.

剩餘風險

項目的特許期超過32年，其中有28年處於運營和維護階段。項目公司在移交項目設施時會遇到質量風險，因為在移交時項目設施尤其是設備的質量已經降低。

Revenue Risk:

Because PPP projects often combine the cost of building new facilities with the cost ofrunning them, all of which is paid for from the revenue budget (unitary charge),this means that revenue budgets must be increased to cope with the additional expenditure. In the Derant Valley Hospital project, revenues generated by the project came from the DGNHST budget. The SPV may, in the long term face a delay in payment should the demand exceed the forecast.

收益風險

因為PPP項目經常是將建造新設施與運營該設施結合在一起，而所有成本均須通過項目收益(一次性收費)來支付，因此這就意味著收益的增加必須能夠應付額外的開支。在DerantValley醫院項目中，項目產生的收益主要來自DGNHST的預算。因此，從長期而言，如果項目需求超過預測，項目公司可能面臨收益支付的延遲。

Operational Risk:

The Health Company may face risks associated with higher operational costs such as the cost of labour, energy and consumables over the concession period. This is currently a major problem in UKNHS Trust hospitals where a large amount of the budget has been eroded by for example, the cost of heating such facilities as world energy prices have increased dramatically. The SPV also faces the risk of not providing the specified standard of services due in part to reducing human resources which will result in a reduction of payment. The Trust will not pay for poor standards of service (see Figure 2).

運營風險

運營公司可能會面臨運營成本增大的風險，如運營階段勞動力、能源和物價成本。此風險目前是英國衛生部基金會醫院項目的大問題，因為大量的資金被種種原因銷蝕掉了，例如世界能源價格飆升而導致供熱成本增加的原因。項目公司還會面臨部分因為人力資源減少而不能提供規定標準服務的風險，從而造成所獲支付的減少，因為基金會不會為不合格的服務付費(見圖2)。

Regulation/Legislation Risk:

A significant consideration in the U.K, for example, the change in environmental law, building regulations or health and safety legislation often emanating from the EU, may result in unanticipated increases in capital or operating cost.

法規/法律風險

在英國還需重點考慮的是諸如由歐盟發布的環保法律、建築規範或健康和安全立法的改變等，這些可能導致預料之外到的資金或運營成本的增加。

Financial Risk:

The ability to service debt, both principal and interest is crucial to this project. Refinancing was considered prior to sanction and was implemented in the early years of operation to mitigate such risk.

融資風險

貸款(包括本金和利息)的償還能力對本項目是非常關鍵的。在批准之前考慮並在運營的前期階段實施了再融資，以減低該風險。

Secondary Market Risk:

This project could be sold to the secondary markets, such as trust funds, pension funds or equity investors seeking long term profit from a project whose revenues are contract led. The sale of such an asset, at some time during the operation period, poses a risk to the NHS since potential new owners are not those who signed the original contract.Innisfree, one of the original financiers of this project are now the second largest owner of hospitals in the UK after the State. Changes incorporate direction of such companies could present the risk of hospitals being managed on the basis of market forces and not health care.

二級市場風險

該項目可以被出售到二級市場，例如主要通過合同交易來獲得項目長期收益的信託基金、養老基金或資本金投資者。這些資產在運營階段某些時候的出售對國家衛生部構成風險，因為潛在的新業主並不是當初籤訂原始合同的人。該項目的原始融資者之一Innisfree，現在是英國所有醫院僅次於政府的第二大業主。這些公司目標的變更對醫院也構成風險，因為其管理是基於市場力量而非健康福利。

1.12 Summary / 總結

Clearly PPP projects require detailed risk assessments. The length of concession and the uncertainties over long periods of time must be addressed prior tosanction. In PPP projects the private sector undertakes more risks than the public sector, therefore identifying, analysing and mitigating risks is paramount to the success of any project.

PPP項目顯然需要進行詳細的風險分析。在項目批准之前必須處理特許期長度和長時間的不確定性問題。在PPP項目中私營部門比公共部門承擔更多的風險，因此，識別、分析和管理風險對任何項目的成功都是極為重要的。

In theUK,PFI/PPP has offered a solution to the problem of securing necessary investmentat a time of public expenditure restraint. According to UK government guidance, a PFI project should demonstrate considerable advantages over the Public Sector Comparator (PSC), thus the PSC should be used as a bench mark for establishing best value.

在英國，當公共開支受限時，PFI/PPP模式對獲得必要的投資提供了解決方法。根據英國政府的指南，PFI項目應該證明有比公共部門比較因子(PSC)更為突出的優勢，因此，公共部門比較因子應被用作基準以實現最大價值。

The Derant Valley Hospital project needed to create best value over a conventional approach. The project was delivered on time and to budget unlike many traditional public sector procurements,which often suffer from delay, cost overrun and compromise on initially planned requirements. One major requirement for a PFI project is the achievement of value for money (VFM). Therefore offering best value for money to the taxpayer was also a major financial objective of the Derant Valley Hospital project. The project’s actual cost was £115 million, compared with the estimated £250 million for the public finance option. The actual cost to the Trust of the building is approximately 4.5 times the initial CAPEX due to the long term repayment period, which is serviced through part of the unitary payment.

DerantValley醫院項目需要超越傳統模式而創造最大價值。該項目如期在預算內完成，而不像許多傳統的公共部門採購項目那樣經常出現工期延誤、成本超支和未能實現原先計劃的要求。對PFI項目的一個主要要求就是要實現「物有所值(VFM)」。因此，為納稅人提供最大的資金價值也是DerantValley醫院項目的主要財務目標。該項目實際成本為1.15億英鎊，而採用政府融資方案則預計達2.5億英鎊。由於分期支付的長期性，其中部分是一次性支付，該項目對基金會的實際成本是最初資金成本的約4.5倍。

The National Audit Office, in 2001, estimated that the hospital would achieve valuefor money of £5 million, and the hospital project could save the Trust between 4% and 14% over the life of the project. This however, is not the case. By virtue of being the first PFI hospital the NHS Trust had to accept a £5 million per annum premium, based primarily on the uncertainty surrounding the long term operation. The hospital currently (2006 accounts) runs at a deficit of £4million per annum.

國家審計署於2001年估計該醫院項目可實現5百萬英鎊的價值，在項目全壽命周期內為基金會節約4%到14%的成本。然而事實上並非如此。由於該項目是英國第一個PFI醫院項目，基金會不得不接受每年5百萬英鎊的額外費用，這主要是基於漫長運營期內的不確定性。該醫院目前(2006年財務報告)每年虧損4百萬英鎊。

As well as value for money, a PFI solution also has to be in line with the wider government objectives, such as environment development and employment opportunities. Under the Derant Valley Hospital project, great emphasis was placed on shaping the built environment. The careand attention given to the design of a room and the quality of space, with respect to the integration of equipment and technology, has helped shape the environment, and takes into consideration the comfort of patients and users of the equipment and contributes more benefits to the environment.

除了物有所值，PFI方案還必須與更廣泛的政府目標相一致，如環境的改善和就業機會的提供。在DerantValley醫院項目中，則更強調建築環境的改善。至於在設備和技術的結合上，關注和重視房間的設計和空間的質量，不僅有利於環境的改善，還考慮了病人和設備使用者的舒適，從而帶來更大的環境效益。

For example, The Hospital Company employed solar control glazing and lowmaintenance building materials, such as aluminum roofing, to keep down longterm running costs, maximising the use of natural daylight for lighting and water cooling, and using off-site manufacturing for faster installation and improved quality control. This has been shown to help improve the well-being of patients and reduce the cost of care without reducing the standards specified.The private sector’s better utilisation of assets and increased operational savings from support service are a core requirement for the viability of most PPPs. In the case of Derant Valley Hospitalcosts of patient care and facilities management have increased to the extent that the hospital is running at an annual deficit.

例如，該醫院項目公司應用了日光控制玻璃和較易維護建築材料，如鋁屋頂，以降低長期運營成本，最大化利用自然光來照明和水冷、採用場外製造技術以實現快速安裝和改進質量控制。事實證明，這有利於改善病人健康狀況和在不降低標準的同時降低護理成本。私營部門更有效的設施利用和配套服務運營成本的節餘是大多數PPP項目可行的核心要求。在DerantValley醫院項目中，病人護理成本和設施管理成本的增加已達到使醫院虧損運營的程度。

1.13 Conclusions/ 結論

Derant Valley Hospital, was the first hospital to bebuilt and operated under the private finance initiative (PFI), and won the British Institute of Facilities Management award for PFI/PPP project of the year in 2001. Because of aninnovative funding approach and the efforts both of the Trust and The Hospital Company staff, the project aimed to achieve the Trust’s affordability target,and thus meet the UK Treasury’s value for money criteria.

Derant Valley醫院是英國第一個採用PFI模式建設和運營的醫院項目，並獲得了2001年度「英國設施管理協會(BritishInstitute of Facilities Management)」大獎。由於創新的融資方式和基金會與醫院項目公司員工的共同努力，該項目目的在於實現基金會的可負擔目標，進而滿足英國財政部的物有所值準則。

Under the Design-Build-Finance-Operate (DBFO) contract, the risks such asconstruction risks, residual risks, and operation risks were allocated to the consortium and have been, to date well managed by The Hospital Company (DareathLtd.). The experience and management skills of the private sector have been well utilised as the consortium is made up from Carillion Service Ltd. (serviceprovider) and Carillion Construction Company. The Carillion construction company handled the risks in the construction period and the project was delivered on time and to budget.

在設計-建造-融資-運營合同下，諸如建造、剩餘和運營等風險分擔給私營聯合體，且至今獲得醫院項目公司(DareathLtd.)很好的管理。私營部門的經驗和管理技能得到了很好的發揮，因為該聯合體是由卡瑞林有限公司(服務提供商)和卡瑞林建設公司組成的。卡瑞林建設公司在建設階段處理風險，並如期在預算內完工。

Experience in providing similar services, in this case high-quality service to NHS Trust and appropriate risk allocation and management which resulted in construction completion on time and to budget achieved value for money in that phase of the project. In the Derant Valley Hospital project, the benefits of PPP are successfully gained and the public objectives were also achieved but at a cost far exceeding the initial estimate.

提供類似服務的經驗，在本案例中是為國家衛生部基金會提供高質量的服務和適當的風險分擔及管理使得項目能夠按時在預算內完成，並在建設階段實現物有所值。在DerantValley醫院項目中，PPP的好處得以成功地實現，公共部門的目標也得以實現，但成本大大超出原先的估計。

Criticism of this hospital, particularly the operation and maintenance element, was aired in a Channel 4 Dispatches programme on 14th August 2006. It stated that the long term O&M contract has allowed the Operator to imposes taggering charges for small day to day maintenance. Examples cited included changing a light bulb and hanging a mirror costing £420 and £200 respectively.The Clinical Director of Surgery condemned the charges saying: 「You just know that when there is a middle man and a private company and there is a whopping charge for every trivial bit of maintenance that it is not value for money – it is blatantly obvious. All this money that has flooded into the Health Service,very little of it seems to have actually got through to patient care. There are extra staff and, luckily, extra doctors and nurses. But there are a lot of people with clipboards」. A Labour Party MP, went as far as saying the PFI/PPP, for this and many other hospitals is 「a money making racket」 and represent an enormous waste of money. An opposition party spokesman stated that the time has come for a fundamental reassessment of how the NHS access capital for their investment projects since PFI/PPP is becoming too unwieldy a tool for encouraging capital investment in the NHS.

2006年8月14日第4頻道的Dispatches節目中提出了對該醫院尤其是對運營和維護部分的批評。節目認為，長期的運營和維護合同允許運營者不斷減少維護費用，例如更換420英鎊的燈泡為200英鎊的平面鏡。外科醫生主管也指責收費，說：「當有一個中間人和私營公司，通過每次微不足道的維護而收取昂貴的收費，你就知道這不是物有所值——這是非常明顯的。所有流進服務公司的錢只有一小部分真正的用在了病人護理上。他們僱用多餘的員工，幸好也有多餘的醫生和護士，但是仍然還有許多拿著紙夾板（不幹實事）的人」。一個工黨議員甚至說對本醫院和許多其它醫院而言，PFI/PPP是「賺錢機器」，浪費了大量的金錢。反對黨的發言人聲明，對國家衛生部如何為投資項目獲得資金進行必要的再評估的時候到了，因為PFI/PPP已變為國家衛生部鼓勵投資而濫用的工具了。

Clearly,this project has not met its financial objectives. Unitary payments are insufficient to meet the required level and the tax payer must subsidize this project by £4 million per year. If this money cannot be found by the Trust then it is highly likely the hospital will scale down its operations and close sections of the facility. Sadly a number of UK hospitals procured as PFI/PPP projects are in the same situation. Currently the NHS has a deficit of £500 million, despite spending £70 billion on hospitals and services.

很明顯，該項目沒有達到其財務目標。一次性支付不足以滿足所要求的水平，納稅人不得不每年補貼該項目4百萬英鎊。如果基金會不能找到這筆錢，那麼很有可能醫院就會按比例減少運營規模甚至關閉部分設施。不幸的是，英國許多採用PFI/PPP模式的醫院都面臨同樣的問題。國家衛生部儘管在醫院及其服務上支付了700億英鎊，但目前仍面臨著5億英鎊的赤字。

When the hospital was first considered as a PFI/PPP project very little was done in terms of value for money compared to the value for money exercise a similar project would need to undergo in today’s market. A lack of clarity as to the long term operations phase, prior to sanction, shows that detailed assessments are required by both the public and private sector to ensure costs can be met without scaling down or reducing the performance specification.

當該醫院第一次被考慮作為PFI/PPP項目時，很少有物有所值方面的考慮，相比之下，當今市場上同類項目必須進行物有所值評估。由於在批准之前，缺乏對長期運營階段的清晰了解，表明公共部門和私營部門都必須進行詳細的評估以保證成本可相抵而不會減少規模或降低績效標準。

Sadly,at least ten major hospitals face closure, despite Government plans to spend a further £1.5 billion on the Health Service over the next five years under the Private Finance Initiative. In some areas there are too many hospitals providing the same or similar services – which is not considered to be value for money. A misconception, however, is trying to compare the capital cost value and the full life cost value. Cost value relates to capital construction(CAPEX) whereas full life cost covers the cost, usually over a period of 30 years for feeding patients, cleaning and maintaining the building, therefore Government will need to pay the private companies £58 billion over the next 30 years or so, although the actual CAPEX is £8 billion.

不幸的是，至少有10個大醫院面臨關閉，儘管政府計劃在下一個五年裡採用PFI模式在醫療服務方面支出15億英鎊。在某些地區，有過多提供相同或類似服務的醫院，他們也沒有實現物有所值。然而，一個誤解就是試圖將資金成本價值和全壽命期成本價值進行對比。成本價值與建設資金相關，而全壽命成本包括所有的成本，通常包括在30多年裡照顧病人、清潔和維護建築物的費用。因此儘管實際的建設成本只有80億英鎊，政府將要在未來的30年支付給私營項目公司580億英鎊。

Finally,the Darent hospital, although operating at a greater cost than estimated was built on time and to budget, something not always common to projects procured by traditional methods.

最後，儘管Darent醫院的運營成本比預期的高，但是能夠按時在預算內完工，這在用傳統方法採購的項目中是不常見的。

References / 參考文獻

1. K&M (2004), Kent & Medway NHS web site,www.kentandmedway.nhs.uk

2. Carillion(2004), Carillion Group web site, www.carillionplc.com

談基建穩增長信號減弱

整個宏觀去槓桿背景下，中央對地方政府融資平臺是收緊的，規範清理PPP項目等，限制了地方資金來源。原來基建投資重點靠政府拉動，這使得基建投資短期降下來。去年年底中央經濟工作會議，淡化了GDP考核目標，地方政府短期內總量壓力小了，將更多精力放到結構調整、質量提升上去。當前房地產投資能形成較好支撐，基建投資不用太高。

——交通銀行金融中心首席宏觀分析師 唐建偉

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