The context  

  • A comprehensive spending review is expected in 2020. This represents the best opportunity for many years to improve resourcing and reset the rules governing capital investment in the NHS.
  • It comes in the context of a prolonged under-investment in facilities across the English NHS, and at a time when the system for allocating capital funding to the frontline is not fit for purpose. The impact of many years of underinvestment in facilities is now obvious to patients, demoralising for staff and of concern to NHS leaders.
  • Without changes, these problems will continue despite welcome recent announcements from the government committing to greater investment in infrastructure and facilities in the years ahead. 97% of trust leaders we surveyed are worried that their organisation’s requirement for capital investment will not be met.

The impact  

  • NHS leaders are clear about the impact of inadequate access to capital on frontline services. 94% of trust leaders said restricted funding posed a high or medium risk to patient experience, while 82% said there is a high or medium risk to patient safety.
  • Constrained capital funding is also stopping trusts from improving how they run. 97% reported high or medium risks to transformation programmes, with 95% saying there was a high or medium risk to productivity and efficiency initiatives.

What the NHS needs 

  • The NHS needs three fundamental changes to help deliver the long term plan. First, the NHS needs a multiyear capital settlement, ideally lasting 10 years and extended annually.
  • Second, the NHS' capital budget needs to be brought into line with comparable economies, meaning funding available to trusts should roughly double. Some of this should be spent on essential maintenance works. However, to rebuild and replace facilities it will also be necessary to fund a national building programme on a scale comparable with the 1960s Hospital Plan, and the investment that took place between 1999-2010.
  • Third, the NHS needs an efficient and effective mechanism for prioritising, accessing and spending NHS capital based on need. A key principle should be that wherever possible capital spending decisions should be devolved to the level where service accountability sits, and to avoid rationing, the national capital spending limit must be high enough with sufficient revenue to fund most investment from trust surpluses.
  • Central funding will be needed to fund large-scale projects, such as rebuilds, that cannot be paid for from surpluses. It may also be necessary for national level action to deal with entrenched problems, such as the maintenance backlog.
  • It is reasonable that capital decisions affecting more than one provider within a sustainability and transformation partnership (STP) or integrated care system (ICS), are taken collectively by providers at a system level. Trusts may also choose to delegate decision making or capital planning to their systems.

The opportunity

  • Investing more in infrastructure offers the opportunity of tangible improvements to health services and would support delivery of the long term plan. These opportunities include: reduced treatment delays due to equipment failure, increased inpatient capacity, expanded diagnostics services, transformed care pathways, more efficient services, and bringing about a fully digitised, technologically enabled service.
  • Taken together, our recommendations represent a package of capital reforms that would put NHS infrastructure on a sustainable footing and improve the lives of all those who use, and work in, NHS services for the long term.