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Feature Data Briefing

NHS urgent facilities repairs: is your hospital on the critical list?

BMJ 2017; 359 doi: (Published 30 November 2017) Cite this as: BMJ 2017;359:j5479

The NHS has built up a nearly £1bn backlog of high risk maintenance over the past three years. This poses a risk of serious harm to patients and staff, reports John Appleby

The £3.5bn windfall for NHS capital spending in last week’s budget comes at a critical time for a growing chunk of badly maintained NHS infrastructure.

As NHS funding over the past seven years has slowed to an historically low rate of around 1.2% a year on average, one tactic to make ends meet has been to switch money from capital to revenue budgets to pay for the everyday costs of keeping services going. This has meant delayed spending on maintaining the infrastructure of the NHS estate—everything from buildings to equipment, IT, and lifts.

As a short term tactic this might make sense; the opportunity cost of fixing a leaky gutter can be measured in reduced spending on direct patient care. But at what point does the cost of not maintaining buildings and equipment directly affect the safety and protection of patients and staff?

NHS Digital reports that the total cost of all backlog maintenance across the English NHS reached an all time high of over £5.5bn (€6bn; $7bn) in 2016-17.1 This is a real increase of over 40% since 2004-05 (fig 1) and is around £1bn more than the total capital budget for the NHS. Most of this increase in backlog maintenance has happened in the three years from 2014-15—a sign perhaps of the growing financial pressure in the NHS. More worryingly, the rise in the cost of backlog maintenance classified as high and significant risk has risen by over 90% since 2013-14.


Fig 1 Cost of backlog maintenance in English NHS has increased by 41% in 13 years1

It is worth stopping to consider what these risk ratings actually mean. High risk is 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.”23 This is not just about fixing a leaky gutter. The cost of high risk backlog maintenance has ballooned in real terms over the past few years from £372m in 2013-14 to £947m in 2016-17—an absolute increase in costs of 154% (fig 2).


Fig 2 Increase in high risk backlog maintenance cost is 154% between 2013-14 and 2016-17 across English NHS1

There is also a huge variation in the costs of backlog maintenance across trusts and hospital sites. Around 8% (20/236) of trusts account for around 50% of the total backlog bill (fig 3). And just one London trust—Imperial Healthcare (which includes Charing Cross, St Mary’s, the Hammersmith, Queen Charlotte’s and the Western Eye hospitals)—accounts for over 12% of the total national backlog cost and one third of the high risk backlog (fig 4).


Fig 3 20 NHS trusts accounted for over 50% (£2.78bn) of total cost of backlog maintenance in 2016-171


Fig 4 Five NHS trusts accounted for over 50% of high risk backlog maintenance cost in 2016-171

With capital to revenue transfers totalling around £3.5bn over the three years from 2015-16 to 2017-18 (Department of Health, personal communication), further transfers planned to keep services afloat, and a sharply growing maintenance backlog bill, the chancellor’s decision to target some extra capital investment at the NHS in his autumn budget is welcome.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.


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