Does the NHS really have a new strategic health infrastructure plan?

Last week the Department of Health and Social Care published a concise 23-page document that trails a new government strategy for investing in NHS land, buildings, equipment and technology. Titled Health infrastructure plan: a new, strategic approach to improving our hospitals and health infrastructure, the document includes several headline announcements that are worth recapping.

There will be an extra £2.7 billion to rebuild 6 NHS hospitals as part of a first wave of investment from 2020 to 2025. There is £100 million of seed funding to develop plans for up to 34 additional hospitals to be built or refurbished as part of the second and third waves of investment from 2025 to 2035 (assuming that future funding actually materialises to allow these seeds to sprout). And there is £200 million for replacing medical scanning equipment, so no scanner in the NHS is more than 10 years old.

And alongside this new funding, there is a promise to develop a rolling five-year plan for further investment as part of a future ‘capital review’ and a commitment to make the capital regime less bureaucratic.

There is undoubtedly some good news here. One of the 6 named hospitals – Epsom and St Helier NHS trust – has over 40 per cent of its estate assessed as ‘not fit for purpose’. When one particular lift breaks down, the trust has to hire ambulances to transfer children across the 20 yards that lie between the main hospital and the children’s hospital. The additional government funding may give some hope to staff and patients that in a few years these problems will be consigned to history.

But aside from this good news, the document leaves a more puzzling overall impression for four reasons: its timing, how the sites were selected, concerns over delivery and its scope.

Timing

'For local NHS leaders trying to plan on constantly shifting sands, the national policy on capital investment must feel more mercurial than strategic.'

The new capital funding comes just one month after the government announced its previous plan to boost capital spending by £1 billion in 2019/20 and provide a further £854 million over five years to upgrade hospitals. This week’s announcement also comes well after the NHS long-term plan was published, and just a few days after local health and care systems submitted their draft five-year strategic plans for transforming how health and care services are delivered. For local NHS leaders trying to plan on constantly shifting sands, the national policy on capital investment must feel more mercurial than strategic.

The health infrastructure plan argues that local and national NHS leaders should never have counted on this money in the first place, starkly noting ‘the NHS long term plan was developed to be resilient to different levels of capital budgets…successful delivery should not be relying on additional funding.’ This may come as some surprise to people in the NHS. From establishing new physical facilities for primary care networks and upgrading radiography equipment, to improving early diagnosis of cancer and using technology to reduce face-to-face outpatient appointments – it is hard to see how many of the headline announcements in the long-term plan could be delivered without the much-delayed multi-year capital investment programme the NHS has been repeatedly promised.

How the sites were selected

Selecting sites for new hospital investments is always an invidious task for any government, but it is a burden that can be made easier by having a clear and transparent rationale for how allocations are made. The health infrastructure plan attempts to be pragmatic by selecting projects that were in the existing pipeline and fairly well developed. This is a slightly different rationale to how previous capital proposals were assessed, which included the benefits to patients, financial sustainability and senior leadership capacity.

But although the upkeep of existing buildings is not the only call on new capital investment, it is curious why some organisations with substantial maintenance problems find themselves towards the back of the queue for the newly announced capital funding (or not in line at all) (see Figure 1). Although the health infrastructure plan promises a more open selection process for the third wave of capital investment in 2030–35, given how quickly capital investment policy has changed in the last eleven weeks, it is hard to predict how capital investment will be managed in eleven years’ time.

This week I found myself in a room with a clinician who was visibly shaking as he asked ‘why did some hospitals win capital investment while we lost out?’. This is a question the people and staff in Kent and Canterbury Hospital might be asking too, as they saw hope of a new hospital dramatically raised and then lowered. Greater clarity and transparency must surely be a key part of the future capital investment programme.

Delivery

There are three concerns over whether we will really see this week’s rhetoric solidify into the bricks and mortar of new hospitals over the next decade.

The first is getting permission to build the new hospitals. This is not a given in cases where building a new hospital is accompanied by service reconfiguration and public consultation. We can only hope that some of the politicians who have welcomed this additional investment do not end up opposing the service reconfigurations that are part of the deal.

Second, what stymied new hospital builds in Liverpool and Sandwell last year was not a lack of funding, it was the collapse of Carillion. The construction industry has already raised concerns over the impact of Brexit on labour availability and the costs of materials – and these may prove to be rate-limiting factors for the government’s ambitions.

And third, there is now a longlist of potential new hospital building plans and a promise of up to an extra £13 billion of funding in future years. But there is no actual capital budget set beyond 2020/21. So we have no idea if this hospital building programme will be in addition to (or come at the expense of) other calls on capital investment – from addressing the backlog of routine maintenance issues to the investment in new primary care premises. For most of the NHS, we will have to wait to see if this announcement proves to be good news and an early glimpse of future investment, or bad news and an early indication that large parts of the future capital budget has now already been committed.

Scope

The final concern is the scope of the health infrastructure plan. In his speech to the Conservative Party Conference in 2018, the Secretary of State for Health and Social Care said something the authors of the NHS long-term plan would certainly echo or at least recognise: 'We’ve got to reform the system……so we spend more time on prevention not cure…and more treatment closer to home…. the era of moving all activity into fewer larger hospitals……and blindly, invariably, closing community hospitals……that era is over.' But by September 2019, the key announcements were focused on the need to build or rebuild acute hospitals.

To be fair, the health infrastructure plan does note that the NHS is not an island and suggests the future rolling five-year investment programme will help modernise the primary care estate (including taking forward the recommendations from the Watson review), improve mental health facilities and support investment in public health and social care and housing.

But aside from the potential to develop community hospitals in Dorset, and the previous announcements made in August 2019 to invest in two mental health trusts in Manchester, little concrete investment has been earmarked for health and care services that lie outside acute hospitals. All of which brings to mind James W Frick’s quote: ‘Don't tell me where your priorities are. Show me where you spend your money and I'll tell you what they are.’

'Announcing a big, bold hospital building programme is not a good thing – whatever the hue of government announcing it. It means that something has gone wrong in the intervening years...'

And ultimately, I think this is what puzzles me most. Announcing a big, bold hospital building programme is not a good thing – whatever the hue of government announcing it. It means that something has gone wrong in the intervening years that means hospitals have been allowed to fall into disrepair. And it means that, despite the ambitions set out in the NHS long-term plan, ministers have once again been unable to resist the allure of the large new hospital to be that palace on a hill.

None of this is easy. Who would honestly say that the crumbling estate of the Hillingdon or Medway or Leicester should not be urgently addressed? And there is no doubt that the government has responded to the concerns of NHS leaders and acted to halt and reverse previous cuts to capital budgets. But we can only hope that when the five-year rolling programme of investment materialises, it is a genuine health infrastructure plan rather an acute hospital plan.