article banner

Agonising about investment is holding back the NHS

Peter Saunders Peter Saunders

We need to make significantly more capital available to the NHS, even above current promises. Matt Custance explains why organisations should be required to meet minimum standards and funding made available to them to support that.

We have a two-tier NHS. Up and down the country, and often within individual organisations. Some parts of it enjoy modern fit-for-purpose infrastructure – and some don't.

We have organisations with the latest in electronic records, modern shiny hospitals, and primary health complexes, and ones where junior doctors run between departments carrying paper referrals, buckets catch water from leaky roofs, and GPs operating out of converted houses. 

This has got to end. Even with the announcement of capital for 40 new hospitals; even with capital for the elective recovery programme and for community diagnostics centres, even with money for digital programmes, including electronic health records, it isn’t enough to fill the gap. In a recent process to determine the eight additional hospitals to complete the New Hospital Programme, 128 bids were received.

The NHS Confederation reports that “81 per cent of healthcare leaders said an insufficient capital settlement could impact their ability to meet estate or service safety requirements, and 69 per cent said it would affect their ability to meet their regular maintenance of their estate”. The same survey found “69 per cent of leaders saying a poor capital settlement threatens their ability to fully embed digital transformation in their care, and even hampers efforts to maintain staff levels or keep appropriate records of patients who need elective care.”

One CEO said that “we have very poor quality accommodation across some of our sites, lack of CQC compliant mental health facilities, lack of single room facilities (IP&C), need emergency capital for sterile services facilities replacement ...We could create arrangements for protected elective facilities but do not have means to do so”.

This is a message repeated across the country.

NHS backlog maintenance (repairs needed but not carried out) is now approaching £10 billion, but only £500 million per annum has been spent to address it historically. However, backlog is not the point. We could stump up £10 billion and eradicate it and still be left with an estate where 18% predates the formation of the NHS and 43% is more than 30 years old.

Not all of that will be unfit for purpose, but when we see 128 bids submitted in an effort to become one of only eight new hospitals, we know that the need is pretty great.

Facilities and technology matter to NHS people

It’s indicative of the scale of the problem that we even need to discuss whether a high-quality working environment is needed. The NHS employs highly qualified professionals who need to collaborate, who work better when they're proud of their organisation. These are people in constant demand from all over the world – They deserve to be in modern, fit-for-purpose estate and that's what we need to fund.

In 2015 Public Health England published an overview of the impact of physical environments on employee wellbeing. It starts by saying that “the surroundings in which employees spend their working lives are an important source of job satisfaction and impact on work motivation and patterns of interaction. They can be as much of a source of pressure as a heavy workload, poor work-life balance or significant organisational change.” This document was not aimed at the NHS, but all workplaces. People need to work in an environment where they feel valued.

A high quality environment and high quality systems make people feel valued. Investors in People is an organisation that accredits workplaces for their commitment to their people. They reference a study by the American Psychological Association which “found that feeling valued at work was linked to better physical and mental health, as well as higher levels of engagement, satisfaction and motivation. All the things that lead to a healthy and productive relationship between employer and employee”.

Meanwhile, in the 2020/21 NHS Staff Survey, only 59.4% of NHS workers would recommend their organisation as a place to work, 46.8% say that they have felt unwell this year as a result of work-related stress, only 52.5% look forward to going to work.

Naturally, we can’t land all of this at the door of Estates and IT – but it can’t exactly help to be working in tired and crumbling estate, lugging paper around, while taking the medical history of an irritated patient who has already given it four times before.

Put simply, supporting the NHS with modern buildings and technology will make NHS people feel valued, leading to more engagement, innovation, motivation and, ultimately, productivity.

Accelerating investment in NHS buildings and technology will help people and industry

It’s easy to think of NHS patients in the abstract, just as it's easy to think of backlog maintenance as an abstract number. But, it’s very different when your family member is sitting in a poorly ventilated, run-down room waiting for surgery which has already been cancelled twice, after being referred for it 18 months ago.

Right now, the elective waiting list is 6.4 million. That’s more than one in ten people. On average, every person in England is seen by the NHS 10 times per year. What kind of experience do we want them to have? We need to answer this question – because we're those people.

Poor estates and technology also impact the industries around the NHS. Healthcare itself is 10% of the economy and the NHS delivers the vast majority of that. But, healthcare also stimulates life sciences, pharma, education, and a range of other sectors. Major corporations regularly make decisions about whether to invest in research and product development here or elsewhere in the world. That means working with NHS clinicians, NHS datasets, NHS patients.

The government’s 'Life Sciences Vision' can’t be achieved without NHS support. That vision aims to attract investors and those investors will be judging the suitability of NHS facilities to host trials, and the suitability of NHS systems and data to support the work. Yet, we offer world-leading scientists crumbling estate and paper records. If you were an investor, or a scientist, where would you go?

We need to find the money – but we also need to change the system for accessing it

We need to find the many tens of billions it would take to bring NHS buildings and technology up to scratch. How bold do we want to be? The recent opening of the Elizabeth Line shows the returns that this scale of investment can bring. However, even if Treasury were to do that, it would take years for the NHS organisations involved to navigate a system – a system which feels to many like it was designed to stop them from spending capital.

We need to simplify the process for approving the business cases needed to commit to capital. Currently, the NHS organisation’s own Board, its Integrated Care Board, the NHS Region, the NHS nationally, and HM Treasury need to approve each case. So people in each of these organisations need to review and comment on the case. Because the mood in approval bodies is shifting towards enabling investment, many of these approvers will now see their job as helping the applicant to make the case as well as possible, but others will see it as being about finding holes in the case.

The people assessing these cases are just that – people. That means that different people in each of these bodies will see different arguments as more or less persuasive and prioritise different things. And, where capital is rationed so very heavily that we can only fund eight projects out of 128 applicants, many assessors will be intensely aware that funding one project reduces the pot for others.

In other words, when you need to get five levels of approval, for three separate cases (and if a consultation is needed, don’t forget the two additional cases from the ICB which will also be needed) when there isn’t actually enough capital, we can’t be surprised that the process is not swift. Providing more capital might ease the rationing concerns, but it doesn’t change the fact that the process is arcane and bureaucratic.

This could be simplified. We've already seen NHS merger business cases reduced from three stages to two, but not NHS capital cases. Other devolved entities face the same number of cases but a less complex hierarchy. 

We need to accept that sometimes modern is more expensive, at least initially. A brand new computer system is going to cost more in depreciation and capital charges than an old one. And the benefits are hard to prove. We know that it will increase efficiency, but we don’t really know by how much. Investment could avoid catastrophic failure – those roof struts we had to put up underneath the RAAC planks are not there for nothing.

Debating when that catastrophic failure could happen feels a bit like Nero fiddling while Rome burns, while replacing only the planks is an opportunity missed to fix the whole building.

A modern building will improve staff satisfaction and engagement and improve patient experience. By how much? We don’t know. Sometimes you have to replace things because they need replacing. Too much time is often expended on trying to prove that there will be a financial (or affordability) benefit to things that, frankly, we're going to have to do sooner or later. By all means, have a rigorous process to assess the alternative solutions and find the best value for money – but let’s not argue about whether a solution is needed. 

Do we want a world-leading health service – or not?

The UK has a decision to make about whether its health service should be modernised or whether we should keep drip feeding modern facilities and technology to the system. Modernisation will be expensive and it’s a leap of faith that it will dramatically improve services. So, do we want a world-leading health service – or not?

For more insight and guidance, get in touch with Peter Saunders.

The future workforce – bringing the vision and present together How do we reconcile a vision for the future workforce?

Get the latest insights, events and guidance about the public healthcare sector, straight to your inbox.