The key Tory manifesto promise to build 40 new hospitals by 2030 was always implausible to all but the most gullible fans of Boris Johnson: but now a new report from the National Audit Office has confirmed that there is no chance of the pledge being fulfilled. 

It states that just 32 new hospitals “according to [the government’s original definition] might be completed by 2030, with a further eight to be completed later. 

At most two of the very smallest schemes might be completed by 2025.

One, of these, the £20m Dyson Cancer Centre in Bath, partly funded by donations from a charity and from the vacuum cleaner magnate Sir James Dyson, is scheduled to include just 22 beds: the other, a new community hospital at Shotley Bridge, which the NAO categorises as a red risk and yet to complete a business case, will be a combination of outpatient facilities with just 16 beds.

Any schemes ready?

None of the six major schemes initially presented as shovel ready back in 2019 (replacing Princess Alexandra Hospital, Harlow; Watford General Hospital; Whipps Cross Hospital, part of Bart’s trust in East London; a new Specialist Emergency Centre for Epsom & St Helier trust in South West London; reconfiguration of University Hospitals of Leicester; and a new wing for Leeds General Infirmary) has even completed a business case.

These schemes, which were at first expected to be completed by 2025, along with two others are now in ‘cohort 3’, “expected to complete by mid 2030”. The NAO estimates the combined cost of these schemes alone as ranging from £5bn-£10bn.

Other projects have also been grouped by the New Hospitals Programme (NHP) into “cohorts,” and where possible the NAO has attempted to estimate the percentage increase in costs for each cohort since funding was allocated to them back in 2020. 

Cohort 1 is almost entirely composed of projects planned and in progress before the 40 new hospitals pledge was made. Its combined cost is now estimated at £2.7bn. It includes the completion of the two major Private Finance Initiative hospitals that were left stranded in early 2018 by the collapse of Carillion, Royal Liverpool (eventually completed last year and operational) and Midland Metropolitan in Birmingham (now not due to open until October next year, with costs having soared by 67% since 2020).

Cohort 2 is a collection of ten relatively smaller schemes ranging in cost from “less than £50m” to £300m. Among the most dramatic increases in projected costs are the doubling in cost of the new Women’s and Children’s hospital at Treliske in Cornwall (up 103% to £300m) and the bigger percentage increase in cost of Derriford Emergency Care Centre in Plymouth (up 137% to £200m). None of the business cases have so far been approved.

How many by 2030?

But the worst-placed are the 14 schemes on Cohort 4. The NAO expects only eight of them to complete construction … after 2030. The total estimated cost of these schemes ranges from £9bn-£19bn. One of the known losers from this group is Imperial College Healthcare Trust in North West London, facing a massive backlog bill for maintenance, whose two major projects, rebuilding St Mary’s Hospital Paddington (upwards of £2 billion) and fully refurbishing and new build at Charing Cross and Hammersmith Hospitals (£1bn-£2bn) have both been told there will be no funding until after 2030.

It is curious indeed that the NAO report, despite being a whole year in the making, misses out a number of important developments, and indeed fails to address a government announcement on the funding of the New Hospitals Programme just a few weeks before publication.

With ministers having agreed to just £20bn of capital funding for the NHP by 2030, rather than the £35bn cost of the full list, Health & Social Care Secretary Steve Barclay confirmed at the end of May that eight schemes were being postponed until the next decade (St Mary’s/Charing Cross/Hammersmith Hospitals (Imperial); Queen’s Medical Centre (QMC)/Nottingham City Hospital; Royal Preston Hospital; Royal Lancaster Infirmary/Furness General; East Sussex Hospitals; Hampshire Hospitals; Royal Berkshire; and North Devon District Hospital.)

The NAO timeline strangely makes no mention of this, or various other early warnings that the whole scheme was going badly wrong, even though these were revealed by the Health Service Journal and in some cases by the national and local press. 

Nor does the report chart the many twists and turns in the way the promise of 40, then 48 “new hospitals” (and the very definition of a ‘new hospital’) has repeatedly been spun and revised by ministers and DHSC comms staff. 

Indeed the NAO has little information on anything prior to the summer of 2021. It fails to note or question the inclusion in the autumn of 2020 of two additional major projects (rebuilding Hillingdon Hospital and North Manchester General) into a new list of eight “pathfinder” projects (now Cohort 3), but without increasing the allocation of capital.   

The NAO also seems oblivious to the July 2021 warning given by the head of the New Hospitals Programme (NHP) Natalie Forrest, who admitted to a conference that the ‘brakes had come on’ for some of the pathfinder projects, and raised concerns over the capacity of the construction industry to complete so many projects by 2030. 

It makes no mention of the letter sent by the NHP at the end of July 2021 to all eight “pathfinder” trusts calling for them to draw up cheaper plans, asking them to submit three sets of plans for evaluation – including an option costing no more than £400m, along with their preferred scheme, and options for building the project in phases. 

All of the five schemes that had published costed plans were initially estimated at more than £400m, and the others are likely to be at least as costly.

Nor does the NAO examine the costs and wasted effort by trust boards that drew up a total of 128 bids in the hopes of becoming one of just eight additional funded schemes to make up the revised 48 ‘new hospitals,’ an exercise which is completely ignored in its review.

Five of those eight places have now been taken by bids to rebuild hospitals entirely constructed between the 1960s and the 1980s from unstable unsafe ‘reinforced autoclaved aerated concrete’ (RAAC). These are now in theory included on the list for new buildings. However the NAO notes the estimated average cost of these is £1 billion each, and neither the plans nor the funding required have yet been signed off. 

However the NAO does raise concerns that work since 2022 on a smaller, cheaper “minimum viable product” (MVP) version of its standardised design for a new hospital (‘Hospital 2.0’) will result in hospitals that are too small. One specific concern that is highlighted is the NHP’s assumption that the new hospitals could operate at a target 95% occupancy, and that length of stay could be reduced by a hefty 12% to increase the numbers of patients using each bed. 

The NAO points out that not only is there little evidence of the achievability and desirability of the reduction on length of stay, but: “England already has one of the highest rates of bed occupancy and one of the shortest lengths of stay per patient in the Organisation for Economic Co-operation and Development (OECD). Currently, 95% occupancy is viewed as highly undesirable and indicative of crisis, and NHS England has a priority to reduce it to 92% across the NHS in 2023-24.”

The NAO concludes that at most just 32 hospitals in England classed as ‘new’ by the definition the government first used could be completed by 2030.

Worse, it appears that the New Hospitals Programme has already managed to spend £1.1 billion of the £3.7bn that has been allocated to the rebuilds, without commencing work on any major project, and the NAO argues that what they have done so far does not represent value for money.

The NAO also expresses frustration at the failure of the NHP to explain any rational basis for their selection of some schemes and exclusion of others. It urges a change in future decision-making:

“When it makes decisions about where to build new hospitals in future, DHSC should appraise options in a transparent way using the best evidence available and should keep full records of why it selects specific projects.”

Rising costs and backlogs

In what is likely to be a serious under-statement of the wider problem of 13 years of inadequate capital investment in the NHS, the NAO points to the consequences of under-investment in what should be routine maintenance of hospital buildings and equipment, noting that the combined backlog has rocketed in real terms from £4.7bn in 2013/14 to £10.2bn in 2021/22.

At the last count 22 hospital trusts in England were facing backlog maintenance bills in excess of £100m, and many more have postponed vital work because of unaffordably high costs. It’s likely these numbers will increase once more when the updated data are published in October. An ITV News report recently revealed that nearly half of NHS hospitals in England have been forced to close wards and vital services due to flooding, power cuts and structural problems. 

A modest promise of a handful of small “new hospitals” at some point in the next decade is unlikely to compensate in the public view for the continued decline and dilapidation of hospital buildings and equipment. 

But after 12 months of waiting for the NAO report many of us will have expected them to deliver a more thorough and wide-ranging review of the overwhelming chaos and failure to deliver on one of the government’s key promises.


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