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The NHS estate backlog grows again


Annual data on the NHS estate is surprisingly fascinating. For example, NHS Digital’s latest estates publication tells us that two NHS hospitals still use coal-fired boilers; the occupied floor area of Addenbrooke’s Hospital would cover 58 football pitches; and Barts Health NHS Trust spent £13.9 million on inpatient food in 2019/20.

But one number in the annual data has stood out from the crowd in recent years: the ‘backlog maintenance cost’, or, how much the NHS needs to spend to get its run-down buildings and equipment back to a suitable condition.

The maintenance figures are not just trivia. Dilapidated buildings and unreliable equipment can lead to poorer patient care and lower productivity – the old scanner that produces low quality images, breaks down during a patient appointment and costs a fortune to maintain; the mental health trust that hires extra staff to observe patients because it can’t remove ligature points.

'Dilapidated buildings and unreliable equipment can lead to poorer patient care and lower productivity'

The recently published figures for 2019/20 show the total NHS backlog is still rapidly increasing, with a large share of this backlog requiring urgent attention (see Figure 1). This suggests that alongside the Prime Minister’s desire to ‘build, build, build’ 40 new hospitals there is a real need to fix, fix, fix some of the other 1,000 NHS sites where NHS secondary care is delivered.

Bar graph showing The cost and severity of backlog maintenance issues with NHS buildings and equipment is rapidly increasing

But even if the latest data paints a familiar picture of rising backlogs, the wider landscape is starting to feel markedly different to last year. As recently as 2019/20, NHS capital budgets were being raided to prop up day-to-day spending. Now, capital budgets are growing once more, the NHS has a new hospital building programme and multi-year funding to replace old diagnostic scanners and outdated dormitory accommodation in mental health providers has been secured.

As the capital funding climate turns from disinvestment to investment, four questions are worth considering.

First, what impact will Covid-19 have on medium-term estate planning? The immediate impact of the pandemic was clear, as the NHS estate was rapidly configured to provide everything from larger waiting areas to more places where critical care and oxygen could be delivered. What is less clear is whether the government will fund changes to the NHS estate to support greater resilience to future pandemics. There will be plenty to learn from East Asian countries that developed more flexible hospital designs and ‘hospital within a hospital’ models that allow greater isolation and compartmentalisation of infection.

Second, what is the strategy for the wider health and care estate? A promise to build new hospitals is good politics – the word ‘hospital’ is far easier to latch onto than a ‘community health care hub’ or ‘primary care hot clinic’. But it is this wider estate that is both lacking a national strategy and is the most likely place where the more integrated and community-based care envisaged by the NHS long-term plan will be delivered.

'Alongside the Prime Minister’s desire to "build, build, build" 40 new hospitals there is a real need to fix, fix, fix some of the other 1,000 NHS sites where NHS secondary care is delivered'

Third, who’s really in charge of local capital and estate decisions? What was once a simple question is now increasingly complex as the NHS embarks on a new ‘system by default’ era of capital planning. In this new world, integrated care systems (ICSs) are given greater say in how local capital funds are used, in the hope that the plans of local NHS providers will be more coordinated. But until the law is changed, it is unclear whether ICSs having a greater say over capital decisions is the same as having a final say –it is not inconceivable that in the coming months a quasi-autonomous foundation trust will make a capital investment decision that drives a coach and horses through its ICS’s wider capital plans.

And finally, why do we keep finding ourselves in this situation? The cycle of running down the NHS estate before declaring the need for a new hospital building programme has bedevilled successive governments. And the NHS currently finds itself in the odd position of knowing what its day-to-day revenue budget will be in 2023/24 without knowing its long-term capital investment budget beyond next year. Clearing the fog around capital budgets until 2023/24 would be a good way of showing that this government is committed to the long-term stewardship of the NHS estate.

One only has to look at Maggie’s Centres to see how the design and upkeep of physical buildings can support better patient care and staff wellbeing. But for too long this integrated planning and long-term thinking has been given short shrift in NHS planning. In his first major speech after being appointed as Health and Care Secretary in 2018, Matt Hancock said he had three policy priorities: workforce, technology and prevention. In his first major speech after being reappointed after the 2019 general election he added a fourth – infrastructure – noting that ‘buildings matter too.’ Indeed.