The operational ask of the NHS cannot be delivered without adequate capital investment. Following the Autumn Statement and the publication of the operational planning guidance, there is now a national drive to recover core NHS services across elective and urgent and emergency care (UEC) and improve productivity. The planning guidance sets a range of national NHS objectives for 2023/24, including improving A&E waiting times so at least 76% of patients wait no more than four hours, reducing general and acute bed occupancy to 92% or below, improving patient flow to ease UEC pressures, and reducing category two ambulance response times to an average of 30 minutes.
The recently published UEC recovery plan recognises that performance recovery is not confined to ambulance services and emergency departments. Wider system collaboration is required between providers across the acute, community, ambulance, mental health, primary care and social care sectors.
This section highlights the role of strategic capital spending in enabling trusts to improve productivity, operational performance and patient care across all sectors. Not only is capital investment critical to maintaining efficient and modern equipment, technology and estates within the NHS, it can also enable a transformative, whole system approach to improving patient flow. This requires full consideration of the capital needs across the acute, ambulance, mental health and community sectors.
Enhancing diagnostic capacity
Replacing and investing in new equipment to increase activity
Enhanced diagnostic capacity has a major impact on health outcomes and improves access to planned care and is therefore a key enabler to delivering on the ambitions of the elective recovery plan. However, the UK has a relatively small diagnostic capital stock compared to similar OECD countries. This means a lower number of CT scanners, MRI units and positron emission tomography (PET) scanners per million people than most OECD countries, and a lower than average spend per person on in vitro diagnostics.
As well as a need for new diagnostic equipment, there is a significant backlog of diagnostic infrastructure more than 10 years old which needs replacing – including unreliable mobile X-ray machines and old CT scanners. The replacement of old equipment and investment in new diagnostic infrastructure is therefore vital.
Community diagnostic centres can ramp up activity beyond acute sites
The provision of community diagnostic centres (CDCs), which are separate from urgent scan facilities, enables patients to access planned diagnostic care more locally. The establishment of CDCs were recommended following Professor Sir Mike Richards' independent review of NHS diagnostics capacity. The SR apportioned £2.3bn for CDCs.
They provide a single point of access in the community and enable trusts to increase diagnostic capacity. NHSE’s ambition is to roll out a network of 160 centres across England, freeing up capacity in acute sites and providing MRI, CT and other diagnostic services closer to patients' homes, thereby also helping to reduce regional inequalities in access.
However, the need to fund the 2022/23 NHS pay award without additional money from the government meant NHSE has had to slow the pace of its transformation programmes and scale back revenue funding due to wider pressures on the national budget, including national technology programmes and diagnostic capacity. It is unclear at this point what the impact will be on delivering the ambitions of these programmes. It is vital however that the government make a long-term commitment to invest in diagnostics.
Estates reconfigurations and surgical hubs to separate elective and emergency care
£1.5 billion was allocated at the SR to create surgical hubs and increase bed capacity. Separating elective and emergency care enables trusts to better deal with Covid-19 waves and winter pressures which disrupt planned elective activity to transform outpatient services. The hubs take different forms on trust sites – integrated, stand-alone and specialist – to enable surgeons to deliver both low and high-complexity surgery. They provide an opportunity to improve and expand surgical training, create a positive working environment for staff, ringfence planned treatment, and avoid excessive cancellations due to wider demand pressures. However, the Royal College of Surgeons notes that workforce requirements can challenge the feasibility of staffing hubs, and that independent evaluation of the units is required to ensure there are no adverse impacts on staffing levels or health inequalities.
Estates reconfigurations can also help reduce infection and prevention control (IPC) risks across inpatient settings, improve patient experience and increase productivity. For example, capital projects which increase the number of bathroom facilities on wards, or investment in respiratory ward infrastructure to support patients requiring non-invasive ventilation (NIV) and high-flow care, thereby reducing patient time in intensive care.
The need to expand bed capacity across the system
Meeting growing demand pressures
Having sufficient capacity to meet demand has always been a critical factor in the NHS' ability to deliver high-quality care. Limited bed capacity and historic underfunding of the NHS estate can go some way to explaining underperformance against some activity targets. For example, evidence shows how admissions delays are directly related to numbers of available beds – a 1% increase in bed occupancy is associated with a 9.5% fall in trusts' probability of meeting the four-hour waiting time target to admit, transfer or discharge patients.
Between 2010/11 and 2018/19, the number of available beds fell by 5% while admissions rose by 5%, and The Health Foundation forecasts that the NHS may need up to 39,000 more beds by 2030 to deliver 2018/19 rates of care. As the Institute for Fiscal Studies notes, while the total number of beds has increased by 1% against pre-pandemic levels, the number of beds available to non-Covid patients in the final quarter of 2022 was still lower than prior to the pandemic.
Expanding trusts’ estate and bed capacity will be essential in helping the NHS meet growing demand. This is particularly important given the current impact of ambulance handover delays. NHSE recently confirmed the profile of the additional money announced at the Autumn Statement – £1bn of revenue funding will help NHSE afford additional capacity, including 5,000 additional beds to ramp up the permanent bed base ahead of next winter. It is unclear what the balance between physical and virtual beds will be.
Ensuring the right combination of beds across systems and the use of virtual wards
Trusts require the right bed capacity in different parts of the country including general and acute beds, but also intermediate care, rehabilitation beds and step-down mental health support. It is vital that capital investment beyond the current SR period underpin sustainable solutions to expand physical bed capacity, and that additional revenue requirements for staffing these beds be met.
National investment in virtual wards has the potential to deliver tangible improvement in patient experience and outcomes, and in systems' performance, by reducing the length of stay in hospital and preventing avoidable admissions. The importance of this approach is underlined in the recent UEC recovery plan. However, there are challenges in scaling up and workforce shortages remain the rate limiting factor, as additional investment in digital capacity will ultimately require a significant boost to staff numbers and the right skill mix for delivery.
Investing in the estate to improve staff wellbeing
Unsurprisingly estates which are not fit for purpose have an impact on the staff who work in them. Repurposed buildings and rooms can make the delivery of services more challenging – for instance, working in cramped conditions where spaces were previously allocated to staff, or in corridors which have been adapted to create more capacity for patient care. This issue was particularly prevalent during the height of the pandemic, when social distancing requirements placed additional strain on physical spaces for care delivery.
Not only are such environments often unpleasant for patients and difficult to work in, but this process takes away spaces which previously enabled staff to rest, eat, or undertake administrative work. The absence of investment in NHS estates has made such practices increasingly common. Staff and trust leaders alike have repeatedly raised the issue of a lack of staff-only spaces in the NHS, and the BMA's recent report highlights the impact this has on staff morale and physical wellbeing.
The physical working environment in the NHS also impacts productivity. The BMA's report notes that 83% of doctors who responded to their survey find the condition of NHS workplaces limits their ability to use technology when delivering care. The most frequently cited issues were matters of basic infrastructure, such as cracked plug sockets, unreliable internet access, outdated computers and lack of office space for clinical staff to undertake administrative work.
While funding for staff-only spaces can be – and often is – taken from budgets set aside for staffing costs, investment in the estate more widely is necessary to ensure that these spaces are functional, remain protected for staff-only use, and improve staff productivity and wellbeing across the board.
Reducing the mental health care backlog and drive long overdue improvements in patient care
Spending Review uplift welcome but there remains a need to improve the mental health estate
In October 2020, the government expanded the funding available to replace outdated mental health dormitories, committing more than £400m up to 2023/24. By March 2022, £220m had already been allocated, with 16 schemes completed and another 22 awaiting construction. The government has also recently confirmed £150m of capital funding initially announced in the SR to upgrade mental health crisis response infrastructure and to procure up to 150 specialised mental health ambulances.
While the Spending Review uplift was welcome, national capital allocations have largely been prioritised towards acute settings. Many trust leaders are concerned that the national priority for elective recovery means there is a corresponding underinvestment in mental health and community services. National capital for mental health and learning disability trusts appears to be limited. This is a particular issue for those mental health trusts aiming to redevelop their estates to improve the quality of care offered to patients, reduce the mental health backlog and improve their efficiency.
The need to improve the therapeutic environment and create low stimulus settings for mental health inpatients
The need to improve the therapeutic environment and create ‘low stimulus’ settings for mental health inpatients is pressing. In November 2021, the Health and Social Care Committee’s Expert Panel noted that service users had highlighted how the therapeutic offer was limited and, crucially, that capital funding had been insufficient to transform the physical estate. The committee noted that significant work is still required to enable adults with severe mental illness to access services in both safe and therapeutic environments.
Mental health inpatient units require significant investment to improve the quality of patient care. Worryingly, the capital maintenance backlog across mental health trusts increased significantly from £425m in 2019/20 to £677m in 2021/22 in cash terms.
There are some particularly outdated mental health hospitals designed in the 1950s which are still in operation. Some units include multiple wards shared by many patients, and male rooms which overlook recreation facilities for female patients, thereby failing to adequately meet dignity and privacy requirements.
Mental health trusts must be given appropriate prioritisation in capital funding decisions at the national and system level, and their role in improving productivity and supporting the delivery of the government’s recovery plans better understood.
Expanding step-down care capacity to relieve system-wide pressures
As already highlighted, national capital allocations following the SR have been largely directed at acute settings with more recent focus on elective restoration, cancer and frontline digitalisation. However, there has been a relative lack of prioritisation for community and intermediate services.
In the context of system capital planning, community providers can find it difficult to access capital. They often must resort to expensive rental arrangements with third party organisations to provide accommodation and expand the community bed base. Given the pressures on emergency care and discharge, additional national funding for community and intermediate services can improve much needed capacity and reduce operating costs.
The process for accessing funding for community trusts can often be more complex given their ties with primary care providers. For example, community providers may lease premises from NHS Property Services and share facilities with a GP practice. Ensuring high-quality integrated care at local level requires clear ownership models and routes for funding to support community providers and GPs to run the primary care estate collaboratively.