Comment / Not enough

It is undeniably good news that the government has reconfirmed its commitment to build 40 new hospitals by 2030 – at least for those organisations to have been given the green light. But despite this significant investment – estimated by health secretary Steve Barclay to be worth more than £20bn overall – it also exposes the huge need for investment across the wider NHS.

It was a convoluted announcement. A number of hospitals were devastated to be told their projects were being delayed to beyond the originally proposed 2030 completion deadline. However, the manifesto commitment to 40 new hospitals remains intact, with the addition of five hospitals where redevelopment is unavoidable because of reinforced autoclaved aerated concrete (RAAC) problems, plus three mental health hospitals, which remain outside the programme officially. 

The programme has been hit by uncertainty and delay – with hospitals watching inflation drive costs higher while they awaited the go-ahead. But even with the health secretary’s ‘re-confirmation’, there is a lot of uncertainty around what is going ahead. Enabling works will get started in many places, but it is not clear whether the £20bn will be sufficient to cover the full costs of the programme – or exactly which options in business cases have been approved to proceed.

But one thing is crystal clear. The promised funding will only scratch the surface of the NHS’s capital needs. Even with the £20bn, there are lots of hoops still to jump through. The government has only committed £3.7bn to the programme to date, with the balancing amount needing to be delivered in future spending reviews. Whichever flavour of government presides over those reviews, it is good this spending commitment has been made. And specific investments will still be subject to the formal business case process.

But what about those not part of the chosen few? It is reported that more than 100 trusts applied for positions in the ‘next eight’ that were originally being sought to extend the programme – plans now dropped. This is clear evidence of a decade of underinvestment in the NHS estate. 

The failure to keep on top of the replacement of NHS infrastructure, while the government pursued its austerity programme to reduce the budget deficit, has led to a situation where there is now urgent, pent-up demand for capital development.
Julian Hartley at NHS Providers puts it bluntly: ‘Too many buildings and facilities are in a dire and deteriorating state.’

Finding a further £16bn for the new hospital programme over two spending reviews covering the years to 2030 implies big annual increases in the NHS capital departmental spending limit. 

But capital funding will need to be more than this. For many organisations, capital development is simply essential. But not increasing capital budgets also has its costs. Many trusts will be spending a fortune each year to keep existing buildings just the right side of functional. And in many cases, old-fashioned, inappropriate buildings will be adding to revenue costs – increasing energy costs, for example. And the current estate may well be a block to improved efficiency and the transformed pathways that are the key to long-term sustainability in the NHS.

The continued drive to digitalise the NHS will also require significant funding. And while the focus may be on new hospitals, primary care has big issues with its estate.
A milestone has been reached with the re-commitment to the new hospital programme, but what is really needed is a much broader long-term capital plan. The government may have had to dig deep to find the £20bn for current redevelopments, but it needs to recognise that far more is needed.