Another year, another leak: is a deteriorating NHS estate now a feature of national policy?

Another year brings another visit from ERIC (Estates Return Information Collection) – the important annual national report on the condition of NHS buildings, estate and equipment.

The news isn’t good.

The cost of tackling the backlog has grown again to £15.9 billion in NHS secondary care facilities (ie NHS trusts providing NHS hospital, ambulance, mental health and community care). Of this, no less than £3.5 billion is for tackling problems with facilities and equipment that could lead to major disruption or ‘catastrophic failure of services’ for patients (Figure 1). And the pain doesn’t stop there – separate data from last month’s BMA premises survey show over 70% of the surveyed GP estate was more than 25 years old and half the respondents said their premises were not suitable for the present needs.

What do these backlog maintenance costs mean in real life? It means one staff toilet shared by 35 staff in a GP practice. It means ligature points left in mental health facilities. And it means you can spend years on a waiting list. It means you can then get a call on the day of your surgery to say your procedure has to be postponed. It means you’ll be told that this isn’t because of a shortage of staff but because the ventilation system has failed in your operating theatre, or because sewage is leaking through the corridor outside the ward you would have been recovering on. I’ve spoken to people who have to make those phone calls. And I’ve spoken to people that receive those phone calls. And believe me, it’s right at the sharp end of the failures of successive governments to plan for the future.

Or rather, it’s the sharp end of failures to deliver on their plans for the future. Remember, this Labour government pledged to deliver the previous government’s New Hospital Programme only to reprofile and delay parts of the programme within months of taking office. The government understandably argues that it inherited a programme that was simply undeliverable and unrealistic, but the newly updated programme means there will be staff, patients and communities who probably won’t see their local hospital refurbished for a generation. And hopes of a fresh wave of public-private partnerships and investment in NHS buildings may turn out to be true – but if so, it will most likely be for building new primary and community health infrastructure projects rather than refurbishing or rebuilding hospitals.

I think the Chancellor does deserve serious credit for saying that capital budgets for long-term spending will no longer be raided to prop up day-to-day spending – particularly at a time when governments of any hue would be tempted to raid capital budgets to pay for higher medicines prices or staff salaries in the present. But despite this commitment, there will still be far more calls on the NHS’s capital budgets than there is money to go around.

So then, where do we go from here? Wes Streeting, the Health and Care Secretary, talks often about the need to prioritise, to deliver, to make tough trade-offs and to stop the NHS going cap-in-hand to the Treasury.

What would that look like in reality? It could look like this – a strategic decision that for the life of the 10 Year Health Plan, hospitals will account for a shrinking share of capital spending in the NHS. That existing capital budgets and new funding sources, like public-private partnerships, should increasingly be prioritised for building the new neighbourhood health service and bolstering out-of-hospital care. That we get better at collecting and publishing data on the condition of the NHS estate that lies outside of hospitals, so we can get a more rounded view of how this strategy is working and what it is delivering. And that the Department of Health and Social Care is honest that this means the condition of some of our existing hospitals will now go into managed decline – with all the poorer patient and staff experience that entails – while this process happens.

As a political strategy, what I’m proposing sounds pretty stupid. But here’s the thing, in one year’s time ERIC will visit again. It will likely show that the condition of the NHS hospital estate is getting worse. At the moment though, it is very difficult to tell if that would mean the government is on-track or off-track on its ambitions for the NHS estate.

We can’t have it all – every pound spent on refurbishing an NHS hospital is a pound that could go on a knacked GP practice or a school with its roof falling in. But even if we can’t have it all, the government needs to provide a better answer to the question of what exactly we are going to get.