Crumbling infrastructure
Patient safety, as well as the NHS’ ability to drive down waiting lists and hit performance targets, is being severely hampered because the NHS has one of the worst records for capital investment in the OECD over the past decade.
The NHS's backlog maintenance bill has risen to over £11.6 billion; this is the cost to bring the NHS estate up to standard. Extra money will be needed to improve and develop the estate to provide services fit for the future.
Capital funding shortfall risks patient safety
In June 2022, NHS leaders were surveyed by the NHS Confederation on access to capital funding that they need to renovate and repurpose old and often extremely dilapidated buildings and estates. The results included the following:
- Nine in 10 NHS leaders said their efforts to reduce the size of the waiting list are being hindered by a decade-long lack of investment in buildings and estate.
- Two thirds said they do not have enough capital funding to meet ‘digital ambitions’ including rolling out electronic patient records.
- Nine in 10 said they cannot transform patient services to meet current NHS England Long Term Plan targets without further capital.
The NHS leaders warned of ageing buildings, run-down estate and outdated computer systems which are risking patient safety.
The NHS received increases in capital funding in the Government’s autumn spending review in 2021, but NHS leaders in the survey noted that this falls short of what is required to make up for the lack of investment in the NHS’ physical infrastructure over the last decade.
What money is available is also proving difficult to access, according to NHS leaders. An ICS leader in the North of England told the survey that delays to a hospital rebuilding programme meant that staff were having to work in “appalling conditions” and that the system was facing a “very large bill for propping up” a dilapidated hospital.
In August 2021, several hospitals in England sounded the alarm over potential roof collapses. There are structural weaknesses in reinforced concrete planks used in their construction from the 1960s to 1980s, which only had a 30-year lifespan.
Backlog maintenance bill continues to increase
There is a major concern over the government’s lack of action on increasing capital investment into the England’s NHS to tackle the massive backlog for maintenance.
New official figures show England’s NHS backlog of maintenance has rocketed by 13.6% in the last 12 months to a massive £11.6 billion. The annual Estates Returns Information Collection makes clear that this total is over and above what should be routine spending on maintenance and replacing/upgrading clapped out equipment:
“‘Backlog maintenance’ is a measure of how much would need to be invested to restore a building to a certain state based on a state of assessed risk criteria. It does not include planned maintenance work (rather, it is work that should already have taken place).”
The latest figure is more than double the 2016/17 figure of £5.5m, and has almost doubled in five years since the 2018/19 total of £6.5bn: it reflects the chronic lack of capital to maintain, let alone expand or improve England’s NHS after 13 miserable years of austerity funding.
And while around half (£3 billion) of the backlogs in 2018/19 were seen as ‘high’ or ‘significant’ risk, that proportion has now grown to 67% in the latest figures.
The Lowdown has calculated that £3.9 billion is classed as ‘high risk,’ which is defined as “where repairs/replacement must be addressed with urgent priority in order to prevent catastrophic failure, major disruption to clinical services or deficiencies in safety liable to cause serious injury and/or prosecution.”
Another £3.9 billion is in the next category, “significant risk,” “where repairs/replacement require priority management and expenditure in the short term so as not to cause undue concern to statutory enforcement bodies or risk to healthcare delivery or safety.”
In summer 2023 a National Audit Office report noted the combined England-wide backlog had rocketed in real terms from £4.7bn in 2013/14 to £10.2bn in 2021/22. Those figures showed 22 hospital trusts in England facing backlog maintenance bills in excess of £100m.
Now 29 trusts have topped the £100m mark, and it’s likely these numbers will continue to increase given the grossly inadequate level of capital funding.
An ITV News report in 2023 revealed that nearly half of NHS hospitals in England have been forced to close wards and vital services due to flooding, power cuts and structural problems.
The problem has been worsened by the years of NHS trusts dipping into capital budgets to help reduce revenue overspends. Most recently, the refusal of the Treasury to give £1 billion extra to help trusts cover the cost of strikes, which means they have to raid their capital and tech budgets.
Of course the NHS capital programme should be about much more than tackling backlogs and preventing safety hazards: equipment needs regular upgrades to keep pace with new technology, many trusts need to refurbish or replace buildings dating back to before the NHS, and many more hospital buildings are upwards of 45 years old.
Fantasy hospital building programme
The 2019 promise from Boris Johnson, then the PM, for 40 new hospitals was repeated time and time again at party conferences and in manifestos.
In July 2022, the National Audit Office announced that it is to review the election pledge to build 40 new hospitals as NHS bosses warn that none of them will be built before the next election in 2024.
The NAO review will investigate the value for money of the new hospitals scheme, and will also look into how many of the 40 are in fact new hospitals rather than extensions or refurbishments. The report should appear in 2023.
The Lowdown has been warning since the autumn of 2019 that Boris Johnson’s promise soon after taking over as Tory leader to build “40 new hospitals” was a con. Labour’s shadow health secretary Jon Ashworth promptly branded them the ‘fake forty.
The government’s claims have been rewritten and spun numerous times since then to avoid the embarrassing truth that there was never anywhere near enough money in the pot to build even the six initial schemes that were in theory allocated funding totalling £2.7bn.
From the outset the financing of the new builds and rebuilds was questionable and misleadingly presented. In August 2019 ministers also promised £1.8 billion in capital for smaller projects to “upgrade outdated facilities and equipment” including upgrades in 20 hospitals. But it was swiftly revealed that £1bn of the £1.8bn of it was not new money at all, but cash already in Trust accounts, which they had been forbidden to spend by NHS England, in a 20% cutback announced the previous month.
Three years later, with the backlog bill for maintenance increased by more than 50% from £6bn to over £9bn, even the normally timid NHS Confederation is now warning that not one of Boris Johnson’s promised “new hospitals” will be built before the election, “And in fact, no work has even started in most cases.”
