Crumbling infrastructure
Patient safety, as well as the NHS’ ability to drive down waiting lists and hit performance targets, is being severely hampered because the NHS has one of the worst records for capital investment in the OECD over the past decade.
The NHS's backlog maintenance bill had risen to over £13.8 billion by late 2024; this is the cost to bring the NHS estate up to standard. Extra money will be needed to improve and develop the estate to provide services fit for the future.
43 of the 215 trusts in England now have backlog bills of £100m or more, adding up to almost £8.6bn – 62% of the total backlog held by just 20% of trusts.
Capital funding key to improving the NHS
Fixing the NHS's crumbling infrastructure is key improving the entire NHS - without fixing this problem it will be difficult to fix the many other issues facing the NHS.
In an April 2025 Lancet article entitled "Why we need to stop talking about productivity in the NHS" Professor Jessemy Bagenal, Senior Executive Editor at The Lancet and an Adjunct Professor at the University of North Carolina, noted that "a fixation on productivity is misplaced" and it must "not be a major drive of how the NHS reorientates itself. Instead, we should aim to fix the long-standing problems laid out so clearly in the Darzi report, starting with filling the infrastructure black hole."
Over a decade of chronic underfunding of infrastructure during the years of the Conservative funding has left the NHS estate in a terrible state. In 2019 The Health Foundation warned that the a short-termist approach taken by government had resulted in "years of declining and inadequate capital spending for the NHS in England, risking patient care and staff productivity."
The effect on patient treatment of a crumbling infrastructure has been known for many years. Back in June 2022, NHS leaders were surveyed by the NHS Confederation on access to capital funding that they need to renovate and repurpose old and often extremely dilapidated buildings and estates. The results included the following:
- Nine in 10 NHS leaders said their efforts to reduce the size of the waiting list are being hindered by a decade-long lack of investment in buildings and estate.
- Two thirds said they do not have enough capital funding to meet ‘digital ambitions’ including rolling out electronic patient records.
- Nine in 10 said they cannot transform patient services to meet current NHS England Long Term Plan targets without further capital.
The NHS leaders warned of ageing buildings, run-down estate and outdated computer systems which are risking patient safety.
The NHS received increases in capital funding in the Government’s autumn spending review in 2021, but NHS leaders in the survey noted that this falls short of what is required to make up for the lack of investment in the NHS’ physical infrastructure over the last decade.
What money is available is also proving difficult to access, according to NHS leaders. An ICS leader in the North of England told the survey that delays to a hospital rebuilding programme meant that staff were having to work in “appalling conditions” and that the system was facing a “very large bill for propping up” a dilapidated hospital.
In August 2021, several hospitals in England sounded the alarm over potential roof collapses. There are structural weaknesses in reinforced concrete planks used in their construction from the 1960s to 1980s, which only had a 30-year lifespan.
Backlog maintenance bill continues to increase
Over the entire 14 years of the Conservative government it did little to improve the infrastructure of the NHS, with little increase in capital investment plus lack of funding forced NHS trusts to raid capital budgets to fund day-to-day running. The result of this lack of action is that the NHS now has a massive bill for backlog maintenance.
The 2016/17 the figure for backlog maintenance was £5.5m, by early 2019, the bill for England’s NHS was estimated at £6 billion. By 2021, it had risen to £9 billion. In 2022, it reached £10.2bn. By the time of the new Labour government was in power in 2024 the most recent figures show the total backlog had rocketed to £13.8bn.
It’s important to note that these are the estimates for overdue work to repair crumbling buildings and replace outdated and badly running equipment – but not to completely rebuild or replace buildings, even when they are riddled with the problem RAAC concrete: those costs would be even higher.
The number of trusts that face backlog bills of over £100m has climbed steadily. In summer 2023 a National Audit Office report noted that 22 hospital trusts in England facing backlog maintenance bills in excess of £100m. In 2024, this had risen to 43 of the 215 trusts in England with backlog bills of £100m or more, adding up to almost £8.6bn – 62% of the total backlog held by just 20% of trusts.
Thirteen trusts face backlogs of over £200m, six top £300m and four are over £400m – with the largest three being Imperial Healthcare, which includes the crumbling St Mary’s and Charing Cross (£814m), Guy’s and St Thomas’s (£504m) and Barts Health – including Newham Hospital and Whipps Cross (£464m).
The South East has the largest number of £100m-plus backlog trusts (10), followed by London (9). The East of England, North East, and Yorkshire both have 7, the Midlands have 5, the North West has 3, and the South West has 2.
A striking new addition to the £100m Backlog Club are two mental health trusts (South London & Maudsley, £151m, and Essex Partnership (£102m).
While some of the figures and placings vary from year to year in the Estates Returns Information Collection (ERIC) figures, it is clear that the decline in the fabric of NHS buildings and the rise in the backlog bill can only be halted by a bold decision to invest in the NHS and restore, repair, and rebuild it as necessary rather than pump money into private sector contracts.
In 2019, The Lowdown calculated that £3.9 billion is classed as ‘high risk,’ which is defined as “where repairs/replacement 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.”
Another £3.9 billion is in the next category, “significant risk,” “where repairs/replacement require priority management and expenditure in the short term so as not to cause undue concern to statutory enforcement bodies or risk to healthcare delivery or safety.”
An ITV News report in 2023 revealed that nearly half of NHS hospitals in England have been forced to close wards and vital services due to flooding, power cuts and structural problems.
The problem has been worsened over the years of NHS trusts dipping into capital budgets to help reduce revenue overspends. Most recently, the refusal of the Treasury to give £1 billion extra to help trusts cover the cost of strikes, which means they have to raid their capital and tech budgets.
Of course the NHS capital programme should be about much more than tackling backlogs and preventing safety hazards: equipment needs regular upgrades to keep pace with new technology, many trusts need to refurbish or replace buildings dating back to before the NHS, and many more hospital buildings are upwards of 45 years old.
What has Labour done for infrastructure
The Autumn budget, the first of Labour's term in office, brought some welcome news for capital spending. Capital spending will rise to £13.6 billion by 2025/26, a 10.9% average annual increase in real terms compared to 2023/24. The spending will rise to £11.8 billion in 2024/25 and then to £13.6 billion in 2025/26. The money will be used to fund plans for new surgical hubs and diagnostic scanners (£1.5 billion); radiotherapy machines (£70 million); and £1 billion for critical maintenance issues with NHS buildings, including those affected by reinforced autoclaved aerated concrete (RAAC); £2 billion for NHS technology to improve productivity and cyber-security; a new fund to upgrade around 200 GP surgeries; and £26 million to open new mental health crisis centres.
However, as welcome as such a large increase in capital spending is, the NHS currently faces an estimated backlog in maintenance of £13.8 billion, a figure higher than the entire capital budget for 2025/26 of £13.6 billion.
In December 2024, the Treasury introduced new rules under which the NHS will be banned from raiding capital budgets to fund revenue gaps. It comes after nearly £900m and £1bn have been moved from capital to revenue budgets in the past couple of years, in part to cover pay, strike and technology pressures.
Hospital building programme update
The Labour government took over the previous government's flagship new hospitals programme (NHP) in mid-2024. The new government instigated a review of the NHP due to concerns over affordability, timelines and prioritisation. The review, “New Hospital Programme: plan for implementation” reported in January 2025 and revealed that five schemes may have to wait until between 2037 and 2039 to start construction.
Eighteen of the 40 ‘new hospital’ schemes, announced with great fanfare in 2019 by Boris Johnson, which were originally due to open in 2030 will not even start construction until 2030.
The review revealed five schemes may have to wait until between 2037 and 2039 to start construction. These are Hampshire Hospitals, Royal Berkshire Hospital, Nottingham’s Queen’s Medical Centre and City Hospital, the Royal Preston Hospital, and East Sussex’s scheme.
A further four projects will now wait until between 2035 and 2038 to start construction. These are both of the Imperial College Healthcare schemes, as well as North Devon District Hospital and Royal Lancaster Infirmary.
Seven hospitals will start construction between 2025 and 2030, in addition to the seven hospitals with RAAC concrete risks, and other schemes which were already more advanced. The seven include North Manchester General Hospital, Hillingdon Hospital, and Milton Keynes Hospital.
Twenty-five schemes had been awaiting the outcome of the review since summer. The announcement means all projects have now been given an indicative window for when construction of their scheme will start, with their funding to be confirmed later.
NHS Providers interim CEO Saffron Cordery said: “Trusts who are part of the new hospital programme account for more than 40% (£5.7bn) of the total bill for backlog repairs and maintenance. Today’s announcement will make a difficult situation even more challenging. While today’s announcement finally gives trusts some certainty and clarity over their long-awaited building projects, this is still a bitter pill to swallow.”
The original 2019 promise from Boris Johnson, then the PM, for 40 new hospitals was repeated time and time again at party conferences and in manifestos.
The Lowdown warned that Boris Johnson’s promise soon after taking over as Tory leader to build “40 new hospitals” was a con, beginning in the autumn of 2019 . Labour’s shadow health secretary Jon Ashworth promptly branded them the ‘fake forty.
The Conservative government’s claims have been rewritten and spun numerous times since then to avoid the embarrassing truth that there was never anywhere near enough money in the pot to build even the six initial schemes that were in theory allocated funding totalling £2.7bn.
From the outset the financing of the new builds and rebuilds was questionable and misleadingly presented. In August 2019 ministers also promised £1.8 billion in capital for smaller projects to “upgrade outdated facilities and equipment” including upgrades in 20 hospitals. But it was swiftly revealed that £1bn of the £1.8bn of it was not new money at all, but cash already in Trust accounts, which they had been forbidden to spend by NHS England, in a 20% cutback announced the previous month.
Three years later, with the backlog bill for maintenance increased by more than 50% from £6bn to over £9bn, even the normally timid NHS Confederation warned that not one of Boris Johnson’s promised “new hospitals” will be built before the election, “And in fact, no work has even started in most cases.”