In a scathing report published today (17 November), the Public Accounts Committee (PAC) lambasted the Government over the New Hospital Programme’s (NHP) lack of progress, given the prominence of the 2020 commitment to build 40 new hospitals by 2030.

The report warns that it’s highly unlikely even to construct the 32 new hospitals that it is now aiming to complete by 2030, after the commitment to build all 40 by the end of the decade was abandoned in May. The PAC wants the Department for Health and Social Care (DHSC) to examine urgently how the NHP can be made to deliver some tangible results for patients, including whether more new hospitals should commence construction sooner using pre-existing approaches to design and contracting.

As highlighted in an earlier National Audit Office report, the MPs reiterate the concern that future hospitals may be too small based on their designs. Current plans, the Committee observes, assume increasing demand for care from a growing and ageing population can be tackled by high levels of bed occupancy; large reductions in patients’ average length of hospital stay; and a significant, recurring transfer of patient care out of hospitals into the community.

These assumptions are described as looking “particularly heroic” in the context of the UK’s growing and ageing population, while the report also points out that no social care plan is currently in place to alleviate the increasing pressure on hospitals.

The DHSC’s desire to develop cheaper and faster methods of hospital construction, using a new standardised hospital design model called ‘Hospital 2.0’, has been impacted by resourcing and design capacity issues, with the development of the design and process now running at least five months behind schedule. This delay has reduced the time available to pilot the new design in real-life scenarios, says the Committee, “risking baking-in and replicating design and construction problems across England”.

The delay has also hindered meaningful engagement between the NHP and the construction industry on the details of the design and the commercial pipeline of work. “There are big questions about the industry’s capacity and appetite to build the required number of hospitals in the new way and to a very tight timetable,” states the report.

The DHSC should aim to be ready to start construction next year of at least one early scheme that uses its standardised hospital design, adds the report, and there should be a particular focus on trialling new clinical infrastructure, such as standardised operating theatres. The DHSC should also amend its Minimum Viable Product version of Hospital 2.0 so it does not result in future hospitals that are too small, and it should set out how these future hospitals fit into its assessment of total required hospital capacity, nationally and by region.

The MPs concede, however, that basing the design of new hospitals on more realistic assumptions of future healthcare demand is likely to increase costs and require a further reset of the NHP. Plus, they propose that the Health and Social Care Committee may wish to consider holding an inquiry into the DHSC’s assumptions about the design of future hospitals.

RAAC and maintenance issues

Several recommendations are outlined to support swifter action on addressing reinforced autoclaved aerated concrete (RAAC) in hospital buildings. Some 42 NHS sites had been confirmed as having RAAC plank construction, with three of these sites now completely eradicated of the material. Seven hospitals are deemed to need a full replacement and will be rebuilt through the NHP before 2030. But the PAC believes that if rebuilding work on these seven hospitals is not accelerated, some hospitals may have to close before replacements are ready.

Among its recommendations, the Committee proposes expediting surveys of the NHS estate and publishing the results in full; reviewing whether the commitment to eradicate RAAC from the NHS should be brought forward from 2035, and whether the existing £685 million fund up to 2024-25 is sufficient; and appointing a named senior official to oversee delivery of its RAAC plan and support NHS trusts to make the right decisions on the safety of RAAC buildings.

The MPs note that the NHS had a record maintenance backlog of £10.2bn in 2021-22 – the underlying cause of which is attributed to the raiding of capital budgets for day-to-day spending. The Committee slated the Government for failing to consider the long-term consequences for services and patient care of diverting billions of pounds in this way. Years of under-investment in the NHS estate has now resulted in a situation that requires urgent action, says the Committee, and the DHSC should not reduce planned capital investment to meet day-to-day needs in future.

The MPs also criticise the Programme for being over-reliant on consultancy services, noting that since its creation, 62 per cent of posts had been filled using consultancy services as of February this year. They suggest that the DHSC should work with the Treasury and Cabinet Office to develop a strategy for attracting into the civil service and retaining the skills it needs to run a rolling programme of hospital construction.

“No confidence”

“The physical edifice that is the NHS is quite literally crumbling before our eyes,” said Dame Meg Hillier MP, chair of the Committee, following the report’s publication. “There was nothing inevitable about this heartbreaking crisis. It can be laid squarely at the door of the decision to raid budgets reserved for maintenance and investment in favour of day-to-day spending. The sharp distinction between capital and revenue budgets exists for a reason. We’re now seeing the consequences of this short-termism visited on patients and services.”

She concluded that the Committee has “no confidence that the NHP will deliver on its current promises” but expressed hope that its recommendations can help to get the Programme back on track.

Commenting on the report, Miriam Deakin, director of policy and strategy at NHS Providers, said that without greater, long-term capital investment, the NHS will be unable to improve productivity and ensure safe, high-quality care.

She remarked: “Too many NHS buildings and facilities are quite simply falling to bits. Mental health, hospital, community, and ambulance services lack money for critical capital projects needed to give patients 21st-century care in modern settings. Thankfully, the NHP will help some trusts to remove substantial, critical risks from their estate.”

She acknowledged that trusts involved in the Programme want certainty that they will be able to afford to build facilities of the necessary size and quality promised, adding that the Government’s next Spending Review would be vital in determining the funding available for trusts in the NHP.

Matthew Taylor, chief executive of the NHS Confederation, said: “Like parts of the crumbling NHS estate, the NHP risks falling apart if capital budgets continue to be raided for day-to-day spending. As the report points out, the repeated diversion of funds to plug revenue gaps is what has got us into this mess, and the consequence is that our buildings are becoming increasingly unsafe to deliver care in and hindering efforts to improve productivity.

“Health leaders have ambitious plans for transformation of their buildings and technology, which would improve patient safety and ways of working, but these have been repeatedly undermined by a short-termist approach to funding.”