The deteriorating state of the NHS estate

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In recent years, the charmingly named ERIC (Estates Returns Information Collection) data collection has contained some deeply alarming news about the condition of NHS buildings and equipment.

The latest data, published today, is no exception. In 2018/19, the total cost of tackling the backlog of maintenance issues in NHS trusts rose by 8.4 per cent to £6.5 billion. And of this over half, £3.4 billion, was for issues that present a high or significant risk to patients and staff (see Figure 1).

Made with Flourish

Now, if these numbers don’t quicken the pulse, a little more context is needed. High-risk issues are identified where repairing or replacing NHS facilities or equipment 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’ (ERIC data definitions).


This has left the NHS with a mix of world-class, state-of-the-art facilities and Victorian hospitals that are no longer fit for purpose.

We are not talking then about carpets that are looking a little shabby, or letting a building become run down when it is scheduled for closure. We are talking instead about facilities and equipment that are so outdated they no longer comply with statutory safety standards. This has left the NHS with a mix of world-class, state-of-the-art facilities and Victorian hospitals that are no longer fit for purpose.

So, what does this mean in practical terms for patients and staff?

One director of an NHS trust told me that broken gutters in his hospital lead to water seeping through the walls when it rains heavily. This happens so frequently that nurses now give ‘water updates’ in their shift handovers, so incoming team members know when they will have to start unplugging electrical equipment – including incubators for newborn babies – from the wall. This is clearly distressing for patients, carers and staff.

And ageing medical equipment is also leading to higher costs and poorer care for NHS patients – as one trust chief executive memorably said, she now has radiologists who are younger than some of the equipment they are using. Old medical scanners are less productive and process images more slowly than their modern counterparts. In some cases, replacement parts are no longer manufactured so the NHS has to bespoke engineer older scanners at a higher cost. Images from older scanners can sometimes lack the granularity and resolution needed for effective clinical care – which leads to poorer patient experience as appointments have to be rebooked at hospitals that have more modern equipment.

And, the situation may be even worse than the ERIC data suggests. First, we only know the ‘works costs’ of tackling these maintenance issues, and the true costs will be higher once fees, VAT and the costs of displacing and disrupting clinical services are included. Second, the ERIC data does not include the maintenance needs of buildings and equipment in primary care, where only half of GP practices report their premises as fit for present needs, or social care, where it has been estimated that 85 per cent of the UK care home stock is more than 40 years old. And finally, ERIC data only records the costs of restoring the existing NHS estate. The capital costs of modernising and transforming the estate – through new community hubs for primary care networks or improved diagnostic facilities that will improve early detection of cancer – are additional to (and competing with) these maintenance costs.

...more than £4 billion of planned capital investment has been reprioritised to support the day-to-day running costs of the NHS.

The story of how we got to this point is well-rehearsed. Over the most sustained period of austerity in NHS funding, more than £4 billion of planned capital investment has been reprioritised to support the day-to-day running costs of the NHS (eg, paying for staff salaries and medicines). This has left the UK lagging behind other countries in the level of capital investment provided to its health service. No wonder then, that several NHS board members I’ve spoken to have been as focused on getting the hospital boilers fixed, as on the long-term strategic integration of health and care services.

What is less clear is where capital strategy in the NHS is now headed – with the capital regime described as akin to ‘driving in fog’ by one system leader. In August 2019, the government made an initial down payment to increase capital spending in 2019/20. This was rapidly followed by a second instalment in September 2019 to build six new hospitals and ensure no scanner in the NHS is more than 10 years old.

But the NHS is still waiting for a multi-year capital settlement and there are some big questions left unanswered, such as when this capital review will happen; how much funding will be provided and for how long; the extent to which this funding will be split across maintenance and modernisation; and where the funding will come from, given the previous Chancellor’s decision to end PFI investment.

And in the interim, as long as these questions remain unanswered, the NHS estate will continue to deteriorate and fall into disrepair. People often talk about the need to create a ‘burning platform’ for change. The platform under the NHS isn’t just burning, it’s crumbling.

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Christopher Shaw

Senior Director,
Medical Architecture
Comment date
21 October 2019

A good piece. I challenge the assertion that the NHS any world-class, state-of-the-art facilities. I can't think of any which would be close to the top 10 of their type. Oddly Mental Health is one area where the UK is quite good.but the recent Sacndinavian psychiatric hospital have raised the bar. In other sectors the ministerial assertion of global leadership is absurd.

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