The NHS’s infrastructure is crumbling and disintegrating – 50% of GP surgeries are not fit for their current purpose, according to the BMA, and recent data shows that £6 billion is needed to complete the backlog of maintenance needed in hospitals and clinics.

Media reports have shown hospitals suffering sewage and water leaks, broken scanners and lifts, and inadequate heating.

Back in 2017, the Naylor report estimated that £10 billion would be needed to make the NHS fit for purpose and deliver the plans that had been drawn up around England to improve the NHS. The plan was for the NHS to raise at least £6 billion of this itself from land and property sales.

So what has happened since the Naylor report – well judging by the current situation, very little of the estimated £10 billion has materialised and what money is available has, has been spent on patching up and making do, rather than modernisation and making the NHS fit for purpose.


So who is responsible for the NHS infrastructure – its buildings and equipment?

The vast majority of the NHS infrastructure, hospitals and clinics, is owned by NHS trusts. Another chunk (12%) is leased from NHS Property Services Limited, a company wholly owned by the Secretary of State for Health and Social Care.

In primary care, the majority of GP surgeries are either owned by GP partners, primary care companies or leased from private landlords.

The upkeep and modernisation of the vast majority of these properties, in particular hospitals, is the responsibility of the NHS trusts. This is covered by the capital budget element of the NHS budget.

The upkeep and modernisation of privately owned GP surgeries is the responsibility of the GP partners or the primary care company that runs the surgery, or the private landlord that owns the surgery, depending on the leasehold agreement. GPs can apply for grants from NHS England to modernise their premises, otherwise they have to take out loans.


What is meant by the capital budget?

There are two types of NHS spending: capital and resource. The NHS’s capital budget is used to fund long-term investments, such as buildings, equipment and IT, plus some maintenance and research and development. The resource budget is for the day-to-day running of the NHS, for staff and clinical services.

In recent years only around 60% of the NHS capital budget reaches NHS trusts, with the rest allocated centrally to areas such as research and development and other capital initiatives.

For each financial year, the NHS trusts, submit their plans for capital spending to the Department of Health and Social Care (DHSC). The sum total of these plans should not exceed the allotted budget for capital spending in the coming year.


Is there a budget for primary care infrastructure modernisation?

In December 2014 the government announced that £250 million per year (over four years) will be available to be invested in modern premises and technology. This was known as the Estates and Technology Transformation Fund”.

Some additional money has been allocated since, including £1 billion in June 2015, and in April 2016, NHS England set out an additional investment of £2.4 billion a year by 2020/21 into general practice, although this was not specifically for infrastructure modernisation.

The BMA survey, however, shows that this has not had sufficient impact on the sector. It appears that much of this money was targeted at creating seven day access to GP surgeries and increasing the workforce, rather than modernisation of GP surgery buildings.


What has happened to capital spending in recent years?

According to the Health Foundation the capital budget for hospital infrastructure has fallen in real terms over the last eight years, with NHS trusts in England seeing a 21% reduction in capital funding.

In 2010/11, capital spending by the DHSC was £5.8 billion, but by 2017/18 this had fallen in real terms to £5.3 billion, a fall of 7%.

As a result, the capital budget in 2017/18 was 4.2% of total NHS spending, compared with 5% in 2010/11.

Although these are the capital budget figures, it does not represent what has been spent over the past eight years. The constraints on the resource budget for day-to-day running of NHS clinical services and trying to keep waiting lists down, has meant that hospital trusts have raided their capital budgets, transferring money to enable clinical work to continue. As a result, work has not been carried out to maintain hospitals or upgrade facilities.

The capital budget for 2018/19 was £5.9 billion, which increased the overall to 4.6% of total NHS spending. This rise was a pittance, however, compared with the £6 billion worth of backlog maintenance that needs to be carried out by NHS trusts, according to NHS digital figures for the year 2017/18.

This backlog figure of £6 billion is the highest on record and over half of the backlog represents ahighorsignificantrisk to safety.

The NHS definition of its high-risk repairs are those that “must be addressed with urgent priority in order to prevent catastrophic failure, major disruption to clinical services or deficiencies in safety liable to cause serious injury and/or prosecution”.

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What effect is the lack of capital spending having on the NHS?

There have been regular reports in the media of hospitals suffering flooding, IT crashes and sewage system failures. These media reports are just the tip of the iceberg, however, there are many other incidents that don’t make it to the media. Any incident interrupts day-to-day working, makes it harder and more stressful for staff to do their jobs, can worry and upset patients, and altogether reduces the efficiency of the NHS.

The BBC series Hospital opened its last series in January 2019 with scenes of a flood in the A&E department of the Royal Liverpool Hospital. Staff spoke of this being a regular occurence and their concerns of electrical failures and its effect on patient care.

A freedom of information request to all hospital trusts in England by The Labour Party, the results of which were reported in July 2019, found that in 2018/19 at least 76 hospital trusts in England recorded incidents caused by “estates and infrastructure failures”.

Replies were received from 170 hospital trusts cataloging a range of incidents. Many involved sewage, including sewage coming through the floor on the ultrasound corridor of one trust in Yorkshire and the Humber.

Other incidents included leaks of wastewater and water into hospital wards, sewage coming up through the bathroom drains, broken lifts, inadequate heating systems, water running down walls and broken scanners.

July 2019 saw fire chiefs threaten to close down parts of four hospitals as they were so rundown they had become a hazard to patients and staff. The hospital trusts must now make improvements or face legal action.

Collapsing infrastructure is not confined to hospital trusts. In February 2019 a survey by the BMA found that only half of GP practice buildings in England are fit for purpose. The survey also found around eight in ten practices said their practices were not suitable for future needs or anticipated population growth.

GP practices who lease their premises from the government-owned NHS Property Services also face the additional problem of rising rents and incorrect service charges. In June 2019, the BMA wrote to NHSPS asking it to address “astronomical” service fees for GP practices or face legal action.

The BMA notes that over the last three years, GP practices leasing their surgeries have seen fees rise without agreement and they have been charged for services that they are not getting.


So is capital spending going to increase?

The capital budget for 2019/20 will be higher than in 2018/19, with some suggestions that it could be £6.7 billion. This budget has yet to be set by the treasury.

However, with a backlog of £6 billion in maintenance at the end of 2017/18, it is clear that the budget will not be sufficient. Furthermore, it is still possible for trusts to siphon off money from this budget to fund day-to-day running of the NHS.

At the start of the 2019/20 financial year, the hospital trusts submitted their plans for capital spending over the coming year to the DHSC. Due to the backlog in maintenance, the trusts naturally planned for a considerable amount of work. As a result, the hospital trusts collectively submitted spending plans that exceed the capital spending limit imposed by the treasury, according to the DHSC.

In a leaked letter seen by HSJ, the DHSC sent an instruction to all trusts, asking them to cut their planned 2019/20 spending to bring it back in line with the central spending limit.


How do we compare to other countries?

Our spending on infrastructure does not compare favourably with other developed countries. According to the Health Foundation’s report, Failing to Capitalise, to increase the NHS’s capital funding in line with the OECD average, the budget would have to be £9.5 billion in 2019/20 – £3.5 billion on top of the current 2018/19 budget, and by 2023/24 an extra £4.1 billion would be needed. Furthermore, this budget would all have to remain in the capital budget, with no transfers to day-to-day running of the NHS.

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