Summary

On 4 September 2025, NHS Providers (supported by PA Consulting) hosted a roundtable of 24 NHS trusts and foundation trusts (FTs) to discuss the future of NHS capital investment. It identified challenges to investing to support the government’s aims for the NHS – but also outlined recommendations that could potentially unlock billions of pounds worth of investment in NHS services.

Capital investment is essential

• Capital investment is critical to deliver the 10-year health plan (10YHP) and government’s ambitions for the NHS, including modernising care, improving productivity, and delivering better patient outcomes.
• Current capital levels are insufficient – despite major increases to the NHS capital budget in recent years, the NHS continues to lag international comparators and other UK public services.
• Capital investment in the NHS represents good value for money. Business cases for major NHS infrastructure projects typically forecast that investment will generate more than a fourfold return over the lifespan of the building.

DHSC should aim to invest 10% of its total budget by 2035

• NHSE/DHSC should produce an NHS investment strategy aligned to a national clinical strategy, to provide a framework for prioritisation and decision making. 
• NHSE/DHSC, together with HM Treasury, should set a trajectory to increase the capital share of health spending annually, with the aim of dedicating 10% of the overall budget to capital investment by 2035. This will require sustained restraint in revenue funding growth, but would have a transformative impact on capital budgets: we estimate that this would raise capital budgets by £8bn a year, which could produce £32bn worth of health, social and economic benefit.

FTs should have more freedom to invest their surpluses by converting revenue to capital

• The 10YHP’s promise to increase capital freedoms for FTs, combined with increasing capital budgets nationally, could offer a powerful incentive for trusts to maximise the value of under-utilised assets. The combination of financial freedom and increased capital spending could potentially enable trusts to raise several billion pounds by selling unused property and reinvesting the receipts.
• Financial freedoms for trusts could also potentially enable trusts to convert revenue spending to capital, at no overall cost to the taxpayer. These include reforms to the public dividend capital regime and introducing new flexibilities for trusts and commissioners.

Greater investment with local authorities creates the opportunity for the NHS to revitalise high streets and bring care closer to people

• Ministers should consider broader funding reforms to enable a more place-focused approach to infrastructure investment. This could bring a range of benefits to communities, for example by bringing NHS services to people’s doorsteps while aiding high street regeneration and providing new affordable housing for key workers.

An NHS bank could help frontload investment and bridge the gap between immediate revenue pressures and long-term productivity gain.

• Policymakers should explore creating an NHS investment bank to enable trusts to borrow so they can access capital. This should include options for financing via NHS cash reserves, the National Wealth Fund and/or HM Treasury funding.

Much of this can be delivered by NHS and DHSC, but help is needed from HM Treasury and government more widely to unlock the opportunity. All the proposed changes could be delivered by 2035, and many of them before the end of this parliament.