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 £9.2 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.


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The NHS leaders warned of ageing buildings, run-down estate and outdated computer systems which are risking patient safety.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 £9.2 billion backlog for maintenance, which is now almost as large as the whole of the current DHSC capital budget, and the cost of running the entire NHS estate (£10.2bn). These figures are for 2020/21 and have undoubtedly risen in 2022.

In 2020/21, the estimated cost of rectifying “high risk” maintenance was £1.5bn, with another £3.1bn required to tackle “significant risk” and £3.2bn for work to tackle ‘moderate risk’.

The problem has been worsened by years of NHS trusts dipping into capital budgets to help reduce revenue overspends, and to make matters worse, the 2019/20 year began with NHS England demanding trusts cut back on their capital spending plans when it became clear that if all of the plans proceeded together they would overshoot the DHSC’s capital departmental spending limit.

In 2020/21 ERIC figures recorded 6,812 “Clinical service incidents caused by estates and infrastructure failure”, plus England’s NHS trusts reported a total of 1,602 “RIDDOR” incidents linked to estates.  The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) which came into force in April 2013 put a requirement on the Trust to ensure that certain major injuries, occupational diseases and dangerous occurrences that occur as a result or in connection with the work done in the Trust, are reported to the Incident Contact Centre (ICC). It is a legal requirement to report a ‘RIDDOR’ and failure to do so could lead to prosecution.

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 the Prime Minister, Boris Johnson 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.”