The latest on the NHS estate

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A grim sense of déjà vu may strike anyone who reads the latest annual data on the condition of NHS buildings and equipment. Once again, the costs of tackling the backlog of maintenance problems has risen and at the end of 2020/21 stands at £ 9.2 billion. This includes a substantial share of problems (classed as significant or high risk1) that require urgent action to avoid harm to both staff and patients (Figure 1).

Figure 1 The cost and severity of maintenance issues with NHS buildings and equipment is still growing

But don’t give in to déjà vu. Because there is a real risk that we become inured to this annual data and ignore the messages it is sending.

One of those messages is that it really does matter that the condition of NHS buildings and equipment is getting worse. In the past two weeks the Care Quality Commission has highlighted how the age and layout of some NHS buildings makes it difficult to maintain social distancing. Other hospitals, which have a type of ‘bubbly concrete’ in their roofs, have been using hundreds of metal supporting struts to minimise the risk of those roofs collapsing. And, as one finance director in the Midlands recently observed, there aren’t that many contractors who can work in a live NHS environment during Covid-19 to help tackle these problems.

Hover over the boxes below to find out more about each Trust.

Figure 2 NHS London has the largest share of backlog maintenance issues

Another message from the data is that the pain is not evenly shared. While no part of England has been immune to the underinvestment in capital over the past decade, organisations in London dominate the list of need – with just five London trusts accounting for more than 40 per cent of the high-risk backlog costs in England in 2019/20 (Figure 2).

This will pose some tough questions for a government that has publicly committed to both levelling up and a national hospital-building programme. Like Janus then, Government and NHS national bodies will have to look in multiple directions at the same time if they are to tackle growing historical backlogs of care with the existing NHS estate, invest in new facilities and services to support new models of care, and do all this in way that avoids leaving parts of the country’s estate behind.

But a final message – and one which doesn’t get enough attention – is that in some ways things are also getting better. One of the two remaining NHS hospitals that operate coal-fired boilers is replacing them with more efficient and environmentally friendly power. Next month the Wolfson Prize 2021, the second largest economics prize after the Nobel, will reward efforts to design hospitals that are environmentally sustainable, connected with their communities and supportive of high-quality patient care and staff wellbeing. And for all the own-goal palaver over how you define ‘a hospital’, the government’s national programmes to build, refurbish or upgrade hospitals, together with a refreshed health infrastructure plan, demonstrate that capital investment in the NHS is now moving up the national priority list.

So what happens next?


September 2021 brought a new £30 billion funding settlement for the NHS, with a substantial portion of this funding dedicated to tackling the growing backlog of planned consultant-led care between now and 2024/25. Look closely, and you will see that less than 2 per cent of this new settlement was for capital investment. But expect capital funding, as the last major area of health funding without a multi-year settlement, to move towards centre stage for the upcoming October 2021 Spending Review and Autumn Budget.

These fiscal events will hopefully provide welcome recognition that NHS buildings and equipment matter. They matter to patients and they matter to staff. And, while it’s not a competition, Ministers might remember that over the past decade the poor condition of buildings and equipment was the original ‘NHS backlog’.

  • 1.‘High risk’ backlog maintenance issues are where the need to repair or replace facilities and equipment must be addressed urgently to prevent catastrophic failure, major disruption to clinical services or deficiencies in safety liable to cause serious injury and/or prosecution (NHS Digital)

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