Over August and September, the government announced much needed capital investment for the NHS. However, has it been enough to address the challenges providers face? In this context, we examine the most recent NHS Digital release on the 2018/19 estates return information collection (ERIC) data set. The information relates to the cost of providing, maintaining and servicing the NHS estate, and gives a national-level picture of the condition of the estate and the effect it has on frontline services. This blog provides ten quick reflections on what the data reveals:
- The cost to bring deteriorating assets back to a suitable working condition increased significantly last year. The total cost to eradicate the capital maintenance backlog in 2018/19 was £6.46bn – an 8% increase on the previous year when the cost was £5.96bn. The backlog has risen each year since 2013/14, and is now 60% higher than it was in 2013/14.
- The backlog has risen much faster than available investment to reduce it. Total investment to reduce the capital maintenance backlog increased by 7% between 2017/18 and 2018/19 to £433m. Therefore, the backlog has grown at a faster rate than the historical increase in investment to reduce it. Despite recent welcome focus by government on NHS capital investment, recent announcements are not sufficient, or universally available to all trusts to clear the backlog, let alone invest in rebuilding the NHS for the future.
- Over half of the backlog represents high and significant risk. A real concern is the high and significant risk that maintenance backlogs have accounted for an increasing proportion of the total backlog figures, rising from 34% in 2013/14 to 53% in 2018/19.
- The proportion of the backlog constituting significant risk has increased while the high risk category remained flat. Significant risk backlog now accounts for 36% of the backlog – up from 34% a year earlier – while high risk categories remained at 17%. The data does not clearly suggest why, though it is important to consider that providers might have prioritised urgent maintenance and infrastructure works over significant risk categories in 2018/19.
- Total capital investment in the NHS increased by 22% from 2017/18 to 2018/19, but this has not reduced the backlog. This increase was driven primarily by increased capital investment for new builds and for improving existing buildings. The proportion of capital investment for new builds increased to 47% of all capital investment.
- The ERIC data shows a continuous fall in private capital investment over recent years. Private sector capital investment fell by nearly 50% between 2017/18 and 2018/19, from £189m to £96m, and has declined from £210m in 2014/15. The data does not tell us why, but there is ongoing uncertainty about the long term role for private investment since private finance initiative (PFIs) fell into disuse.
- The capital maintenance backlog is larger for acute providers than it is for non-acutes, but this isn’t the whole picture. To allow us to compare the backlog between types of trust we looked at the maintenance backlog as a proportion of turnover. Although the backlog is greater in acute trusts, we explicitly know that mental health, community and ambulance providers have estate issues that may not show up in this data. For example, mental health trusts often have well maintained buildings but have dormitories that need to be reconfigured to reflect modern clinical practice.
- Trusts in deficit tend to have much bigger backlogs than those in surplus. Across all providers in deficit, the median capital maintenance backlog as a proportion of turnover is 6%. However, for providers in surplus, the median is 3%. This is likely due to surpluses having been reinvested in facilities, while this will not have been possible for those in deficit – particularly those in long term financial difficulty.
- Patients pay the price for the mounting backlog, and the scale of the problem is gathering pace. Between 2017/18 and 2018/19, there was a 25% increase in clinical service incidents. This number has increased year on year for the past two years. It is important to note the new definition of 'clinical service incidents', which refers to the number of incidents caused by estates and infrastructure failure that led to clinical services being delayed, cancelled or otherwise interfered with. This categorisation has been broadened to ensure failures by services contracted out to subsidiaries, Local Improvement Finance Trusts, NHS Property Services Ltd and PFIs are included in the figures. It is unclear what impact this technical change has had though, as many trusts with PFIs were already reporting incidents under the old definition. The rise in reported incidents reflects what trusts are telling us about how estate issues can have a direct impact on patient care and safety.
- The capital maintenance backlog will not be addressed without the government meeting the three asks of NHS Providers' 'Rebuild our NHS' campaign. While recent commitments by the government on NHS capital are welcome, including £1.8bn in August and £2.8bn in September, this is not enough. Firstly, the NHS needs a multi-year capital settlement. Secondly, the government must commit to bringing the NHS capital budget in line with comparable economies, allowing the NHS to pay for essential maintenance work while also investing in long term, transformational capital projects. Thirdly, an efficient and effective mechanism must be established for prioritising, accessing and spending NHS capital based on need, in consultation with those planning and delivering services.