Amid the turmoil of the change of health secretary and chancellor there is another major question mark over the credibility of another major Tory policy commitment that was key to Boris Johnson’s election victory in 2019 – the promise of “the biggest, boldest, hospital building programme in a generation.”

The National Audit Office is to review the election pledge to build 40 new hospitals as NHS bosses warn for the first time that none of them will be built before the next election in 2024.

The NAO review will investigate the value for money of the new hospitals scheme, and will also look into how many of the 40 are in fact new hospitals rather than extensions or refurbishments. Although they will not report until next year, the findings will certainly prove uncomfortable for whoever is in Downing Street when they are published.

For readers who have not followed this sorry saga of rhetoric disconnected from resources, which has now dragged on almost three years, here is an update.

The Lowdown has been warning since the autumn of 2019 that Boris Johnson’s populist promise soon after taking over as Tory leader to build “40 new hospitals” was a con. Labour’s shadow health secretary Jon Ashworth promptly branded them the ‘fake forty.

The government’s claims have been rewritten and spun numerous times since then to avoid the embarrassing truth that there was never anywhere near enough money in the pot to build even the six initial schemes that were in theory allocated funding totalling £2.7bn.

From the outset the financing of the new builds and rebuilds was questionable and misleadingly presented. In August 2019 ministers also promised  £1.8 billion in capital for smaller projects to “upgrade outdated facilities and equipment” including upgrades in 20 hospitals. But it was swiftly revealed that £1bn of the £1.8bn of it was not new money at all, but cash already in Trust accounts, which they had been forbidden to spend by NHS England, in a 20% cutback announced the previous month.

NHS Providers, the body representing trusts, was calling for sustained increases in capital funding arguing that:

“The NHS buildings and equipment budget has been relentlessly squeezed year after year. Over the last five years we’ve had to transfer nearly £5bn of that money to prop up day to day spending. As a result, the NHS now has a maintenance backlog of £6bn, £3bn of it safety critical. The NHS estate is crumbling and the new NHS long term plan can’t be delivered because we don’t have the modern equipment the NHS needs.”

Following the announcement that new hospitals were to be funded, NHS Providers responded:

“It’s not just these six hospitals who have crumbling, outdated, infrastructure – community and mental health trusts, ambulance services and other hospitals across the country have equally pressing needs. We also need increased capital spending to support changes in the way care is delivered, including in IT and digital, to deliver the new NHS long term plan.”

Nonetheless the promise of 40 new hospitals was prominent in the 2019 Conservative manifesto, as Boris Johnson successfully used it to convince enough pro-Brexit Labour voters in the so-called ‘Red Wall’ seats of the midlands and the north that they could trust the Tories with the NHS.

Three years later, with the backlog bill for maintenance increased by more than 50% from £6bn to over £9bn, even the normally timid NHS Confederation is now warning that not one of Boris Johnson’s promised “new hospitals” will be built before the election, “And in fact, no work has even started in most cases.”

The Lowdown – Pursuing the truth about the 40 new hospitals

Johnson’s plan to build 40 hospitals yet to stand-up

Truth behind Johnson’s “40 new hospitals” claim 

Checking up on Johnson’s fake forty new hospitals

Propaganda stepped up as new hospital schemes are stalled

New hospitals won’t end bed shortages

Speeded up hospital building: a threat, not a promise

48 new hospitals? Only one by 2025

Desperate Downing Street spin doctors have again tried to weasel their way round the issue by claiming “The funding for the initial schemes has been approved and by 2024, six hospitals will be completed with a further 30 under way.”

The problem with this is that it’s quite clear that 30 schemes will NOT be under way by 2024, and even if six projects are completed by then, they will not be the new hospitals that were promised by Johnson. The £2.7bn promised was then, and is now, quite obviously nowhere near enough to build all of the schemes that were misleadingly portrayed as ready to go, let alone any more.

The initial funding for the six schemes that was approved back in 2020 has not been increased, and unless there is an abrupt U-turn by the new Chancellor Nadhim Zahawi, ministers have been insisting that there will be no further increase in capital or revenue funding for the NHS.

So it’s already certain that none of the six hospital projects supposedly given the immediate go-ahead in 2019 will be completed by 2024 – and increasingly unlikely that many of these, if any, will have even started.

The initial six, which were expected to share the £2.7bn initial capital allocation for new builds and be delivered by 2025, were named as Epsom & St Helier trust in SW London, Whipps Cross Hospital, in NE London (subsumed into the morass of the Barts Health Trust); Leeds  Teaching Hospitals Trust plans to build new ‘hospitals’ for adults and children on the Leeds General Infirmary site; West Hertfordshire Hospitals Trust’s plan for a new hospital, (controversially in Watford, the least accessible site); a new replacement for Princess Alexandra Hospital in Harlow; and a reconfiguration of services by University Hospitals of Leicester, with controversial plans to reduce from three sites: to two.

Projected costs had soared even before the latest leap in inflation (the West Hertfordshire project was initially allocated £400m in 2019, well short of the £750m estimated actual cost of a new hospital in the Trust’s Strategic Outline Case: but the most recent estimate of the cost is now £1.2 billion – three times the initial allocation and over 40% of the total capital set aside for all of the first six schemes).

There have been local delays to all six schemes at local level – but the overwhelming problem has been the inadequate allocation of capital, and more recently insufficient funding even to pay for the preparation of plans and business cases, compounded by rows between ministers over the relative priority of NHS projects.

All this has been compounded by the ineptitude of the New Hospitals Programme (NHP), set up in 2020, which employs an astonishing 170 people but has yet to deliver a single functioning project, or even make an honest statement about the desperate lack of resources that makes their task impossible.

The NHP was set up in October 2020, when the new hospitals story was completely rewritten by Department of Health and Social Care spin doctors. They re-announced the £3.7bn allocation of capital to cover a variety of new hospitals and various smaller capital projects – and declared that the task was now to deliver “40 hospitals, with a further 8 schemes invited to bid for future funding to deliver 48 hospitals by 2030.”

This was coupled with a substantially changed list of projects, including eight schemes that had not been anywhere to be seen in the initial ‘fake forty’:

Four were described as “In build”: Midland Metropolitan Hospital; Cumberland Cancer Hospital; Royal Liverpool Hospital; 3Ts Hospital, Brighton. All of these pre-date Johnson’s 2019 pledge. The hugely-delayed, PFI-funded Royal Liverpool Hospital and Midland Metropolitan Hospital projects were signed off under David Cameron, halted by the collapse of Carillion in January 2018 – and are still not complete. While Liverpool is now expected to open this year, the Midland Metropolitan has again been delayed and is not expected to open until spring 2024, six years late.

Four more previously omitted schemes were listed as “Pending Final Approval”: Moorfields Eye Hospital, central London; Northgate Hospital, Morpeth; Major Trauma Hospital Salford; and a new “Defence and National Rehabilitation Centre,” in Loughborough.

In addition, the six supposedly ‘funded’ initial schemes listed above were also included, with two more schemes, rebuilding Hillingdon Hospital (serving Boris Johnson’s constituency) and North Manchester General Hospital, were added to the priority list – to make eight ‘pathfinder’ schemes. But no more money was added to the money in the pot to finance this first round of new projects up to 2025.

These 16 were lumped together with schemes for five small community hospitals in Dorset, a newly announced rebuild of the small Shotley Bridge hospital in Durham, and various other projects, many of them refurbishment or extensions, to make up a total of 40 ‘new hospitals’.

The same press release also announced for the first time that there would be a “competition for 8 further hospitals including new mental health hospitals.” This was eventually launched in the summer of 2021 and led to an avalanche of applications from desperate trusts facing massive backlog bills for maintenance,  several of which are even facing the potential collapse of busy hospital buildings.

Among the hospitals facing this threat are Crewe’s Leighton Hospital (Mid Cheshire); Hinchingbrooke (North West Anglia FT); Wexham Park (Frimley Health FT); James Paget Hospital, Lowestoft; Queen Elizabeth Hospital, Kings Lynn, and West Suffolk Hospital (Bury St Edmunds)

Several of these hospitals are in such a dire state that it could be cheaper to knock them down and rebuild. In the most recent backlog maintenance statistics, for example Mid Cheshire Hospitals abruptly announced a massive £373.9m backlog, with estimates that it would take 15 years and cost £555m to replace all of the crumbling concrete planks, while West Suffolk Hospital (the only hospital of this type on the list of new hospital projects) reported a monster backlog of £634.9m.

In Kings Lynn, where the Queen Elizabeth Hospital is now held up by a staggering 1,500 props, the estimated cost of repairing the roof  is £500m.

But even the danger of hospitals collapsing has not brought any progress. In early July 2021 the leader of the New Hospital Programme, Natalie Forrest, admitted that “the ‘brakes had come on’” for some of the pathfinder projects, and claimed there were concerns over the capacity of the construction industry to complete so many projects by 2030. She also admitted that several of the pathfinder schemes were unlikely to start before 2023-24.

However, Ms Forrest avoided any mention of other key issues: the need to alter and expand some schemes to allow extra space because of Covid, and new carbon neutral requirements. These mean more excess costs above the allocated levels of funding, and further question the affordability and viability of the pathfinder schemes – and many of the others in the queue for funding.

The funding issue came to the fore three weeks later, at the end of last July, when the New Hospital Programme team wrote 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.

The prospect of a price cap of £400m would be a major problem: all of the five schemes that had published costed plans were already over £400m, and the others are likely to be at least as costly. Cutting back these hospitals to comply with the £400m cap could mean disastrous reductions in beds and services.

In August 2021 the HSJ revealed the leaked content of  a new government PR “Playbook” with a hugely contentious interpretation of what constituted a “new hospital”.

The Playbook’s bizarre concept of “new hospitals” got off to a shaky start as then Health and Social Care Secretary Sajid Javid was widely ridiculed on social media and in some mainstream news coverage for his claim to be opening one of the “48 new hospitals” – when he was in fact opening only a new cancer centre on the Cumberland Infirmary site in Carlisle. The building had been commissioned years before Johnson made his promise.

The Playbook also re-divided the various schemes into five “phases”:

Phase 1 – “In-flight” schemes – the four that were under construction or shortly to start construction and were currently anticipated to complete construction between 2021 and 2025.

Phase 2 – “Agile” schemes – were smaller projects that are flexible in delivery and have the potential to complete construction earlier in the decade – currently expected to complete 2024-26.

Phase 3 – Pathfinder schemes  – larger and more complex schemes whose plans were “relatively advanced” and “currently anticipated to start construction between 2023-24 and complete in the period 2026-28.”

Phase 4 – Full Adopter schemes – will be delivered “in the latter half of the decade”

Phase 5 – “Next eight” schemes – “to be identified under the current open process and delivered in the latter half of the decade”.

Of the list of 32 projects which the Playbook insisted had to be described as “new hospitals” at least 11 are clearly additional or refurbished wings or units alongside the main hospital, and five more are small-scale community hospitals with limited services.

The Playbook even embarrassed hardened comms professionals. It was immediately criticised by leaders of two professional bodies seeking to uphold standards in public relations. Chartered Institute of Public Relations president Mandy Pearse said: “Accuracy and honesty in public sector communications are important in maintaining public trust. This comment within the Playbook is ill-judged.”

Public Relations and Communications Association chief Francis Ingham told PR Week: “It is important that public communications are factual and neither misleading nor exaggerated. To any normal person, a new wing does not equate to a new hospital. In the interests of public confidence in such announcements, we would urge honest, straight-forward accuracy.”

In January this year the HSJ revealed that a staggering 128 trusts – almost two thirds of all trusts in England – had submitted bids to be one of the “next eight” schemes, to bring the total of new hospitals to 48.

However a number of these projects were admitted to cost in excess of £1bn, with many more in excess of £500m. Without a massive expansion of the capital funding, these stand no chance of being adopted.

In any case more than nine out of ten of all the submitted proposals will simply be rejected, although the deadline for announcing which schemes have been selected (and therefore which have been dumped in the bin for the indefinite future, shattering any hopes of repairing and improving services in many areas that have been offered completely false hope) has now been postponed to the end of the year

The Infrastructure and Projects Authority (IPA) has given the New Hospitals Programme an “amber/red” ranking, meaning its delivery “is in doubt with major risks or issues apparent in a number of key areas”.

In an attempt to show some results despite limited resources, the NHP has shifted ground, sidelining the initial 6 ‘pathfinder’ projects that were supposedly ready to roll in 2019, and prioritising ten smaller-scale schemes described as ‘agile’, hoping for “delivery between 2024-26 despite initially being scheduled for 2025-2030.” The larger rebuilds are now slated for the “latter half of this decade.”

Meanwhile any hope of even starting the ‘pathfinder’ projects has been further diminished by cuts in funding for the trusts concerned to draw up plans and business cases. In one way this makes sense, since any plans drawn up that can’t be funded are simply a waste of time and money; but of course nobody is admitting this to be the case.

The HSJ reports that the eight trusts are due to receive just £1m each towards this preparatory work in 2022-23, far short of what each trust needs. West Hertfordshire Hospitals Trust said in May that as a result it has had to “stand down” its external advisers, leaving the Trust unable even to complete the outline business case, an essential first step to getting the plan endorsed and releasing the necessary funding for the project.

Whether the new Chancellor, under pressure from Johnson to cut taxes, will at the same time decide to pump extra capital into the NHS, and whether the new Health and Social Care Secretary – former Treasury minister and Johnson’s chief of staff Steve Barclay, whose first statement claimed “This government is investing more than ever before in our NHS and care services” – will even ask for more money, remains to be seen.

Some already see Barclay is an unlikely champion of more investment: HSJ deputy Editor Dave West comments on Twitter: “Officials say experience with Barclay means they are expecting “no more money and you’re all useless” as the mantra from the new health and social care sec — along with insistent pushing of flawed ‘reform’ ideas.”

In any case it’s clear that if the funding limits set by Rishi Sunak’s spending review remain in place the promise of 40 new hospitals will remain as a major broken pledge into and beyond the next election, whenever that may be.

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