Rishi Sunak’s budget said next to nothing about the NHS, and thus indicates a continuation of austerity-driven spending limits on the NHS after the decade of disinvestment and decline since 2010.

But another major concern is the absence in the budget of any increased capital investment into the England’s NHS to tackle the massive £9 billion backlog for maintenance – which according to the latest ERIC figures rose almost 40% in 2019-20, and is now almost as large as the whole of the current DHSC capital budget, and the cost of running the entire NHS estate (£9.7bn).

The estimated cost of rectifying “high risk” maintenance is £1.5bn, with another £3.1bn required to tackle “significant risk” and £3.2bn for work to tackle ‘moderate risk’.

To give an idea of the relative scale of this problem, one expert told Healthcare Design & Management:  “Five years ago I was talking about the ticking timebomb of backlog maintenance, which was then around £5billion, and now it’s nearly double that.

“When you think the whole NHS capital budget is around £4.5billion a year, then even if we did nothing else for the next two years but spend it on backlog maintenance, we wouldn’t address all the issues, and more would build up. The ones deemed to be ‘significant’ risk would then become ‘high’ risk very quickly. It is quite alarming.”

The problem has been worsened by years of NHS trusts dipping into capital budgets to help reduce revenue overspends, and to make matters worse, the 2019/20 year began with NHS England demanding trusts cut back on their capital spending plans when it became clear that if all of the plans proceeded together they would overshoot the DHSC’s capital departmental spending limit.

In the summer of 2019 NHS Providers said in a letter to trust chief executives and finance directors that the lack of capital posed “considerable reputational risk for trusts and the NHS,” and warned: “One description of the current situation is that trusts are facing significant patient safety and operational risks. 

Now in response to the shocking rise in the backlog – which ran up to March 2020, and therefore does not include much of the pandemic impact – Chris Hopson, chief executive of NHS Providers, said: “It shows how rapidly our very-old NHS estate is falling into disrepair, putting patient lives at greater risk and making it much more difficult for frontline staff to provide the right quality of care.

“More worrying still, over half of this is for work of ‘high’ or ‘significant’ risk. In short, this problem poses an increasing threat to safety. It’s also impacting directly on the response to the pandemic.”

Last year 45% of NHS trust leaders surveyed by NHS Providers reported their estate was in poor or very poor condition.

As Chris Hopson suggested, the estates figures show clinical service incidents caused by estates or infrastructure failure have now increased in each of the past three years to 5908 in England’s 224 trusts. The trusts with the largest number of estates-related clinical incidents in 2019/20 include Guy’s and St Thomas’s (612), North East London FT (375), Moorfields Eye Hospital (353), East Suffolk and North Essex (329), Lewisham and Greenwich (273), and Southport and Ormskirk (240).

A clinical incident is one caused by estates and infrastructure failure which results in clinical services involving 5 or more patients being delayed by at least 30 minutes, cancelled or otherwise interfered with, including where estates and infrastructures failed to mitigate against external incidents  (e.g. utility power failures where the Trusts backup power system failed to offset.)

There are questions over how fully these figures are reported, however, since several trusts in responding to Freedom of Information requests have stated, like East Sussex Healthcare, that their incident reporting system “does not identify if an incident is a ‘clinical service incident”.

Evidence of the impact of disrepair can be found in some annual reports. Pennine Acute Hospitals for example reported on the list of issues:

“In July 2019, the NCA [Northern Care Alliance, an NHS Group formed by bringing together Pennines with Salford Royal NHS Foundation Trust] was granted a £9.95m emergency capital loan from NHS Improvement/England. Almost half was invested in the heating and energy infrastructure at North Manchester and Oldham hospitals, with the remaining funds being invested to support water safety works, fire alarm upgrades, roof repairs, emergency lighting systems, estates asset management systems, medical gases, windows, fire doors and fire compartmentalisation works.”

Just as well the money was made available.

By contrast Southampton notes the poor state of the estate led to a poorer rating from the CQC:

“Maternity received a ‘good’ rating overall and in all individual categories other than safety which recorded a ‘requires improvement’ rating, while outpatient services were rated ‘requires improvement’ – both largely due to the quality and age of the estates and facilities”

University Hospitals Morecambe Bay reports bravely battling on against the odds:

“Despite outlining our case for investment and the real, adverse effect our estate has on continuity, productivity, patient experience and money, we have nonetheless maintained operational performance.”

Harlow’s Princess Alexandra Hospital, one of those on the government’s list of six new hospital projects to which real funding has been allocated, notes that they will have to keep services running in the old building until at least 2025, and rank the “concerns about potential failure of the trust’s estate and infrastructure and consequences for service delivery” as one of its greatest risks.

In addition to clinical incidents, ERIC figures record almost 13,000 other “estates and facilities related incidents” during 2019/20, with problems concentrated in some trusts. University Hospital Southampton topped the failure league, notching up an average of almost two incidents per day (727 for the year, in addition to 300 false fire alarms).

Other trusts in the top ten of estate incidents include North Bristol (598); Morecambe Bay (594); Pennines (436); Princess Alexandra (408); Barts (392); Sheffield Teaching Hospitals (380); NE London FT (366); Bolton (347); and Moorfields (317). Ten more trusts had 200 or more, and another 20 trusts had over 100 incidents.

Moreover England’s NHS trusts reported a grim total of 1,693 “RIDDOR” incidents linked to estates.  The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) which came into force in April 2013 put a requirement on the Trust to ensure that certain major injuries, occupational diseases and dangerous occurrences that occur as a result or in connection with the work done in the Trust, are reported to the Incident Contact Centre (ICC). It is a legal requirement to report a ‘RIDDOR’ and failure to do so could lead to prosecution.

Of course the NHS capital programme should be about much more than tackling backlogs and preventing safety hazards: equipment needs regular upgrades to keep pace with new technology, many trusts need to refurbish or replace buildings dating back to before the NHS , and many more hospital buildings are upwards of 45 years old.

But while plans drawn up prior to the pandemic for new hospitals now need to be revisited and re-costed, coping with the aftermath of Covid-19 also requires capital. Without additional money for investment there is no realistic prospect of remodelling many hospitals to adapt to the post-Covid need for social distancing and improved infection control, reopening thousands of closed beds and restoring their capacity to treat routine and emergency patients as well as Covid.

Rishi Sunak’s budget has turned out not to be a forward looking plan at all, but a prescription for further, dangerous decline. He must be told to think again before more deterioration is reported in the next ERIC figures – to be compiled in October.

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