Investment in NHS capital funding is critical to safety, care quality and efficient use of NHS facilities. This has become increasingly clear during the pandemic when trusts with old and outdated estates and equipment found it more difficult to reconfigure old sites to accommodate social distancing and infection, prevention and control.
Yet the latest release of the estates return information collection (ERIC) data from NHS Digital shows there has been a substantial deterioration in the NHS estate. Covering 2019/20, the figures give us the most accurate picture of capital investment across the service, highlighting the tremendous pressure facing the provider sector's infrastructure.
Trusts began the 2019/20 financial year having been asked by NHS England and NHS Improvement to scale back their capital spending plans.
Their initial assumptions, driven by an increasingly urgent need to carry out essential maintenance and repair works, would have risked exceeding the overall spending provided for under the Department of Health and Social Care's capital departmental expenditure limit (CDEL).
Later that year, an additional welcome £1bn was added into the CDEL to boost NHS capital spend, allowing existing upgrades to proceed and tackling the most vital infrastructure projects.
However, the ERIC figures show that even with this additional capital injection, trusts' estates have still deteriorated significantly.
The maintenance backlog
The cost of bringing deteriorating assets back to a suitable working condition – known as the maintenance backlog – continues to rise. In 2019/20 the backlog was £9bn. This represents a 40% increase from the 2018/19 figure which stood at £6.46bn, and double the level seen five years ago.
Moreover, over half of the total outstanding capital maintenance is constituted as 'high' or 'significant risk'. (as Fig. 1 shows).
These figures point towards a clear escalation of risk which is jeopardising patient safety. In 2019/20, the number of clinical service incidents rose by 23% compared to 2018/19. Clinical service incidents caused by estates and infrastructure failure have risen in each of the past three years. Indeed, 45% of trust leaders surveyed by NHS Providers last year said their estate was in poor or very poor condition.
Why is this backlog figure so high? The data shows that parts of the NHS estate are deteriorating faster than trusts can invest to maintain it. In 2019/20, while £516m was spent by trusts on addressing these urgent maintenance works, the total backlog grew by five times this amount (as fig. 2 highlights).
Looking to the future
In 2021/22, the NHS capital budget has been increased to begin work on new hospital building, hospital upgrades, and to replace old diagnostic equipment and to make further progress on mental health inpatient facilities. This will result in many outdated and inadequate facilities being replaced and will reduce the backlog for trusts that receive funding.
Yet, while this is welcome, it is clear that the backlog is a systemic problem that requires a strategic response with sufficient funding to upgrade facilities across ambulance, community and mental health settings as well as further investment for acute hospitals. The growth of the maintenance backlog reaffirms the need to create a capital allocation system that recognises that trusts need to be able to access capital and have the freedom to spend it in a timely way.
It will always be appropriate for strategic projects to be signed off nationally, and for systems to collectively make decisions about capital works large enough to affect systemwide plans and budgeting. But individual organisations should have delegated authority to proceed with backlog maintenance and other small-scale works: where they do not have this freedom, investment will be delayed unnecessarily, to the detriment of efficiency, productivity, and patient safety.
The condition of the NHS estate has made responding to the COVID-19 pandemic more difficult. Trusts operating with old estates have managed under incredibly challenging circumstances to reconfigure their facilities to ensure adherence to infection control measures – but trusts with older estates report it has been more challenging to scale up capacity and convert facilities.
It is clear that trusts will need to spend more to address urgent repairs. The outstanding maintenance costs will continue to rise - heightening the risk to patient safety - unless the eradication of the backlog is prioritised. This will require a major increase in the amount of capital available to all trust types, dedicated to maintenance, repair and replacement of ageing facilities.
It will therefore be important to ensure you use your holding to account duty to gain assurance from non-executive directors (NEDs) about the impact the maintenance backlog has on your trust's ability to transform and improve services. You could also explore in your questioning with NEDs the degree of risk these outstanding repairs present to patient care.
The design and upkeep of buildings used across all parts of the provider sector has a material impact on patient care. The maintenance backlog ultimately presents a risk to the ability for trust leaders to discharge their duties and ensure patient safety standards across their estates.