What the recent ERIC data tells us about the state of NHS buildings
The release of the ERIC (Estates Returns Information Collection) data this week has provided us with the annual check-in on the condition of NHS hospital buildings and equipment. This data covers all NHS organisations that deliver secondary care, including mental health and community trusts.
The maintenance backlog has continued its steady increase, and now stands at £13.8 billion – which means the cost of eradicating problems in just the secondary care estate exceeds the entire capital budget of £11.8 billion for the financial year. That £13.8 billion includes a scale of risk, with repairs categorised in terms of urgency and impact, with a 15% increase in the 'high-risk' backlog in the past year – where failure to address repairs urgently could lead to serious injury to both staff and patients as well as major disruption to services.
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To understand more about what this kind of disruption looks like, I spoke to Epsom and St Helier University Hospitals, who are waiting for the review into the New Hospital Programme to confirm whether their new specialist emergency care hospital will be built, alongside the much-needed investment to make their existing buildings fit for purpose. Their current buildings are deteriorating faster than the trust can fix them. Due to a key corridor flooding, ambulances have had to transport patients the short distance from one part of the hospital to another this year.
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This is not an enviable situation to be in and is replicated across lots of different NHS trusts; however, it is only part of the story. While the ERIC data is able to tell us rather a lot about what is happening in the secondary care estate, this level of granularity, or even higher-level data, is not available in the public domain for other settings, such as primary care. As the Institute for Government noted this year, what we do know about the state of the primary care estate is often pieced together from ‘surveys, one-off reports and anecdotes’. Lord Darzi’s report provided us with such a snapshot, finding that 20% of the GP estate pre-dates the founding of the NHS in 1948 and 53% is more than 30 years old. Many practices are in converted houses, with very limited space and scope for expansion and more difficult to modernise.
Working environments in general practice also include dealing with disruption stemming from estates not being fit for purpose. One practice in Brighton I spoke to was struggling to manage on-the-day access for patients as their duty consulting room often floods. However, without comparable data – a primary care ERIC – it is difficult to make a strong case for capital investment.
This has been borne out by the focus of the recent capital settlement in the Autumn Budget. It can’t be overstated that the budget was a good moment for capital in general. As Lord Darzi pointed out, for too long we’ve been undercapitalised as a health care system, so this was a year of relative feast compared to the famine of the past. There have also been some welcome signals from this government that they ‘get it’ on capital. First, we’ve seen the Chancellor commit to redressing the short-term approach over recent years by providing multiyear capital budgets, set for five years and extended every two years at spending reviews. Second, the long-term trend of cannibalising capital budgets to fund gaps in day-to-day revenue spending has been outlawed – with the new fiscal rules explicitly ruling out this kind of transfer. These feel like good foundations for next year’s comprehensive spending review and 10-year plan to build on to ensure we have the modern facilities and equipment the health care service needs.
However, if we look at the decisions taken within that more generous settlement, we can see two things: first, that much of this capital funding is already earmarked, and second, within this, the investment is heavily weighted towards secondary care. While there was £26 million to open new mental health crisis centres and a new £100 million fund to upgrade around 200 GP surgeries, there was also £1.5 billion for new surgical hubs and diagnostic scanners; £70 million for new radiotherapy machines; £1 billion for critical maintenance issues with NHS buildings (including those affected by reinforced autoclaved aerated concrete (RAAC)); and £2 billion for NHS technology to improve productivity and cyber-security.
Although investment in primary care, often the poor relation, is very welcome, to paraphrase Professor Kamila Hawthorne when she appeared in front of the Health and Social Care Select Committee earlier in December, £100 million is nice but it isn’t quite the same as £1 billion, and it is earmarked to cover only 3% of the more than 6,000 practices in England. But equally, £1 billion feels like a small sum when you think about the scale of the backlog in secondary care. There simply isn't enough to restore NHS facilities to where they should be, let alone to do the modernising and transforming that we know needs to happen to enable the delivery of care in a way that meets the ambitions of the government’s three shifts, particularly moving care from hospitals to the community.
However, as the Secretary of State stresses, it is not all about money. As Beccy Baird, Senior Fellow at The King’s Fund, pointed out to the Health and Social Care Select Committee, there are some arcane rules around the way the general practice estate can be used that, if removed, could support better joined-up, integrated working locally.
But much of it definitely is about investment. Given the financial climate for the health and care system is tight and set to stay that way, there will inevitably be trade-offs and prioritisation within the capital envelope. Hopefully, some of those choices will be made off the back of a better understanding of needs across the entire NHS estate.
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