Intended for healthcare professionals


Old buildings and out of date facilities are costing the NHS dear

BMJ 2022; 378 doi: (Published 25 July 2022) Cite this as: BMJ 2022;378:o1862
  1. Saffron Cordery, interim chief executive
  1. NHS Providers

“We operate 21st century healthcare from 19th century buildings. It is increasingly unsustainable.” So said one NHS leader responding to NHS Providers’ survey of trusts included in the government’s flagship New Hospital Programme (NHP), underpinned by its manifesto commitment to build 40 new hospitals by 2030.

Against a backdrop of ongoing political turbulence that has seen a recent change of health secretary and a Conservative party leadership campaign, and just as the National Audit Office said that it will launch a review into the NHP, it’s vital that the problems of capital investment in the NHS are tackled urgently.

Last week’s sweltering temperatures have shown that the NHS estate is not built to cope with extreme weather. Some trusts, for example, had to scale back the number of planned operations as theatres got too hot.

Delays and growing concerns about the lack of progress and funding, however, mean that what was billed as the biggest hospital building programme in a generation is on shaky ground.

Our survey findings paint a picture of doubt and frustration. Half of trusts said that their building projects are underfunded and around two in five said their schemes were behind schedule—by up to four years in some cases. Some don’t even have a starting date. These delays also raise concerns about the ability of the government to uphold its commitment to deliver a further eight hospitals before 2030.

Trust leaders are anxious that the benefits they expected to be able to deliver for patients and their communities are increasingly at risk, in some cases getting further beyond reach every passing day. Many trusts say public confidence that plans will get beyond the drawing board is eroding fast.

In October 2020, Boris Johnson announced £3.7bn for trusts to make headway on the 40 NHP schemes. That’s not enough for every trust in the programme to deliver their preferred option during the current spending review period.

Trusts are ready to start construction but are waiting for confirmation of funding. Those forced to delay now face inflation driven rises in the cost of building materials and supply-side problems including labour shortages.

The NHP shows how complex it can be to deliver a national programme for which the government is responsible, but for which local parts of the NHS are accountable to their communities. When having to announce delays, trusts need government support to manage important relationships with staff, partners, the public, and MPs and to explain why we are where we are.

Much of the NHS estate is in a bad way. So much so that in some cases bulldozing and rebuilding is the only feasible option. Without proper investment, leaking roofs, broken boilers, and outdated technology—more Blockbuster than Netflix, to use a recent analogy—don’t get fixed or replaced, with damaging knock-on effects on the quality of care and patients’ safety. The maintenance backlog is a huge problem right across the NHS.

The NHP is a fantastic opportunity to transform the fabric of the NHS and the delivery of healthcare by providing badly needed renewal for acute, mental health, community, and ambulance services. If delivered properly, it could also support the “levelling up” agenda by reducing health inequalities and driving long overdue improvements to patient safety, service capacity, and the recruitment and retention of valued, professional staff.

Trusts in the NHP agree that with the right amount of government support their schemes will mean better care, experiences, and outcomes for patients and help them to boost productivity. It is vital, therefore, that the government properly funds these schemes and gives trusts the freedom to get on with it as soon as possible.

The NHS turned 74 recently, but it shouldn’t be stuck with old buildings and facilities well past their sell-by date.

If we don’t build modern, safe settings now where staff can give patients first class care it will cost the NHS dear for a long time to come.


  • Provenance and peer review: not commissioned, not peer reviewed.

  • Competing interests: none declared