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 had risen to over £13.8 billion by late 2024; 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.
43 of the 215 trusts in England now have backlog bills of £100m or more, adding up to almost £8.6bn – 62% of the total backlog held by just 20% of trusts.
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The NHS leaders warned of ageing buildings, run-down estate and outdated computer systems which are risking patient safety.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
Over the entire 14 years of the Conservative government it did little to improve the infrastructure of the NHS, with little increase in capital investment plus lack of funding forced NHS trusts to raid capital budgets to fund day-to-day running. The result of this lack of action is that the NHS now has a massive bill for backlog maintenance.
The 2016/17 the figure for backlog maintenance was £5.5m, by early 2019, the bill for England’s NHS was estimated at £6 billion. By 2021, it had risen to £9 billion. In 2022, it reached £10.2bn. By the time of the new Labour government was in power in 2024 the most recent figures show the total backlog had rocketed to £13.8bn.
It’s important to note that these are the estimates for overdue work to repair crumbling buildings and replace outdated and badly running equipment – but not to completely rebuild or replace buildings, even when they are riddled with the problem RAAC concrete: those costs would be even higher.
The number of trusts that face backlog bills of over £100m has climbed steadily. In summer 2023 a National Audit Office report noted that 22 hospital trusts in England facing backlog maintenance bills in excess of £100m. In 2024, this had risen to 43 of the 215 trusts in England with backlog bills of £100m or more, adding up to almost £8.6bn – 62% of the total backlog held by just 20% of trusts.
Thirteen trusts face backlogs of over £200m, six top £300m and four are over £400m – with the largest three being Imperial Healthcare, which includes the crumbling St Mary’s and Charing Cross (£814m), Guy’s and St Thomas’s (£504m) and Barts Health – including Newham Hospital and Whipps Cross (£464m).
The South East has the largest number of £100m-plus backlog trusts (10), followed by London (9). The East of England, North East, and Yorkshire both have 7, the Midlands have 5, the North West has 3, and the South West has 2.
A striking new addition to the £100m Backlog Club are two mental health trusts (South London & Maudsley, £151m, and Essex Partnership (£102m).
While some of the figures and placings vary from year to year in the Estates Returns Information Collection (ERIC) figures, it is clear that the decline in the fabric of NHS buildings and the rise in the backlog bill can only be halted by a bold decision to invest in the NHS and restore, repair, and rebuild it as necessary rather than pump money into private sector contracts.
In 2019, The Lowdown 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.”
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.
The Autumn budget, the first of Labour's term in office, brought some welcome news for capital spending. Capital spending will rise to £13.6 billion by 2025/26, a 10.9% average annual increase in real terms compared to 2023/24. The spending will rise to £11.8 billion in 2024/25 and then to £13.6 billion in 2025/26. The money will be used to fund plans for new surgical hubs and diagnostic scanners (£1.5 billion); radiotherapy machines (£70 million); and £1 billion for critical maintenance issues with NHS buildings, including those affected by reinforced autoclaved aerated concrete (RAAC); £2 billion for NHS technology to improve productivity and cyber-security; a new fund to upgrade around 200 GP surgeries; and £26 million to open new mental health crisis centres.
However, as welcome as such a large increase in capital spending is, the NHS currently faces an estimated backlog in maintenance of £13.7 billion, a figure higher than the entire capital budget for 2025/26 of £13.6 billion.
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.”
