The NHS estate continues to deteriorate

ERIC (Estates Returns Information Collection), the annual data on the condition of NHS buildings and equipment, is back with some alarming news, especially in the context of a return to raiding capital budgets to maintain day-to-day spending.   

The ERIC data comes just a month after the government published plans to offset the financial pressures created by industrial action by dipping into NHS capital budgets to cover day-to-day running costs of the health service. It shows that the NHS needs to spend £11.6 billion to return its run-down buildings and equipment to a suitable condition. This is not about a lick of paint but ensuring safety for patients and staff, and preventing potential major disruption or failure of services because of the state of equipment and buildings. 

What is the impact of the poor condition of equipment and buildings? In September, the Chief Financial Officer of NHS England, Julian Kelly, told the Public Accounts Committee that every day ‘hospitals are having to shut units and decant patients into other spaces’. St Peter’s Hospital in Essex, a former Victorian workhouse, has had to relocate some inpatient services to other hospitals this winter amid issues with a leaking roof, weak flooring and broken lifts. And Queen Elizabeth Hospital in King’s Lynn has more steel props to stop RAAC (reinforced autoclaved aerated concrete) collapsing in its buildings than it does hospital beds. Underinvestment impacts the delivery of care, causing disruption for patients, and adding to the burden on staff who have to negotiate working in dilapidated buildings on top of their workload.  

Two key pieces of analysis by the Institute for Government and the Institute for Fiscal Studies have identified capital underinvestment as one of the key areas contributing to lower-than-desired NHS productivity. In 2019, the UK spent 0.33% of GDP on capital investment in health care, compared to an average of 0.48% for comparable countries, and this trend of underinvestment has been consistent for nearly 20 years. The trend was exacerbated by the siphoning of £4.3 billion from capital budgets into revenue as a response to the lack of resource in core day-to-day NHS budgets between 2014/15 and 2018/19. This short termism is likely contributing to the lower-than-expected hospital productivity seen since the Covid-19 pandemic, as staff try to work with less equipment and outdated technology in deteriorating buildings. The Institute for Government put it well saying, ‘Ultimately, if large increases in the workforce are not matched in capital almost any system will get less productive.’ The idea of spending money on buildings and equipment might have seemed less important than directing it to ‘the front line’ but now staff are facing additional operational pressures ‘generated by the level of backlog maintenance’.   

Faced with this state of affairs, ideally what is needed is the injection of long-term thinking and action but the situation seems to be deteriorating not improving. The government’s flagship New Hospital Programme, meant to be delivering the manifesto commitment of 40 new hospitals, has been widely criticised for delays and failure to deliver. The National Audit Office stated that the government ‘will not now deliver 40 new hospitals by 2030’ against the definition set by the government in 2020.  A difficult position to be in, especially as nearly two-thirds of NHS trusts in England submitting bids to the programme were rejected. The programme also focuses on new hospitals which are only the tip of the iceberg when it comes to the need for capital investment in the health and care system outside of this. For example, despite rising demand and the ambition to shift care out of hospitals, lack of capital investment in primary and community care means that 22% of primary care premises predate the NHS and these services often don’t have the technology, data and connectivity they need to better co-ordinate patients’ care.  

Compounding this situation now are the financial challenges facing the NHS, which have placed it in the unenviable position (again) of having to cannibalise capital budgets to keep services running day to day, further reducing investment in buildings and technology. And the long-anticipated NHS-wide capital review, due to set an overall strategic direction for NHS capital, has been kicked into the long grass again with a revised publication date of summer 2024 (despite originally being planned for winter 2022–23).  

With all this in mind, what will happen next if nothing changes? Well as Sir Robert Naylor's 2017 review prophesised, without action we will inevitably continue to have a ‘deteriorating NHS estate increasingly unfit for purpose’. A shaky foundation that could undermine the government’s productivity drive.