Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: The “40 new hospitals” pledge was always a mirage

BMJ 2023; 381 doi: (Published 07 June 2023) Cite this as: BMJ 2023;381:p1259
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

In 2020, when he was prime minister, Boris Johnson pledged to build “40 new hospitals by 2030,” with a “further eight schemes invited to bid for future funding” as “part of a package worth £3.7bn.”1 This also formed a key part of his 2019 election manifesto.2 News last week that building works had stalled and that this promise would not be met illustrated serious failings at the heart of government.3 Which is bad news when the NHS is so politicised and centralised.

This should come as no surprise. In 2021 the government’s own Infrastructure and Projects Authority said on the record, as reported in the Health Service Journal,45 that what was now called the New Hospitals Programme had been given a “red” risk rating because of serious concerns about leadership, timescales, and resourcing after two separate reviews. Even before the “40 new hospitals” announcement, two new urban hospitals in Liverpool and Sandwell had gone way over budget and timescale, before the private finance initiative contractor Carillion collapsed, leading to delays and sections of the work having to be redone.67

It was also widely reported in 2021 that NHS England had ordered NHS hospitals to refer to any refurbishments, new wards, or new units on existing hospital sites as “new hospitals,” in a desperate attempt to hit the target of 40.8 Even in 2020 it was reported that most of the “new hospitals” would in fact just be consolidation on existing sites.9 This is not just spin—it’s straight up lying. I’d hope that hospital bosses would refuse to do it.

By May 2023 the health secretary, Steve Barclay, had told both parliament and the news media that seven of the new hospitals would not be built by 2030 and that many of the others were not “new builds” at all.1011 He also said in a Commons statement that seven hospitals (five not included in the initial target of 40) had been made using autoclaved aerated concrete, meaning that they would be unusable after 2030 and so also needed replacement.12 The Health Service Journal then reported that 123 hospitals had applied to be one of the sites but had been turned down—a huge amount of work and consultancy spending around the NHS for no gain.13

Plans by the government and NHS England for elective and urgent care recovery1415 have also contained commitments to new buildings, including add-ons to emergency departments, additional acute bed capacity, and more than 100 community diagnostic hubs. We’ve yet to see if this follows a similar pattern of over-promising, underfunding, inadequate logistical planning or risk assessment, and delivery failure.

Crumbling estates

Hospital leaders in the NHS both before and after Barclay’s announcement have made it clear that their buildings are increasingly unsafe and well beyond their use-by date.161718 Lack of capacity in overcrowded clinical facilities is a risk. Lack of investment in IT, diagnostic equipment, and hardware are no friends of service improvement or safe working. Unsafe NHS estates make modern, safe healthcare hard to deliver and the jobs of clinical staff harder.

Research by the Health Foundation showed that the UK spends about half the OECD average (only 0.27% of its total budget) on capital expenditure and projects.19 This has gone on for many years, with a tendency to raid planned capital budgets to prop up day-to-day NHS operational expenditure—which may ultimately prove to be a false economy. The constant focus on recruiting or retaining frontline clinical staff with no parallel plan for capital investment is a false and self-defeating binary.

Beyond all of this, Johnson’s original pledge of “40 new hospitals” was as arbitrary as his pledge of “50 000 new NHS nurses”20: a big, populist number for soundbites. Still, why only 40? How about a systematic look at all hospital sites on the NHS estate? Why “new,” when in some cases a refurbishment or new build for part of the site would be fine? Why not close some hospitals if they’re too small or run down to be viable? And why not invest more in primary and community health facilities? They may be less iconic, glamorous, or visible than hospitals, but they’re just as essential.

The New Hospitals Programme and the promises around it were ill conceived, rushed out, badly planned, and badly executed, with poor engagement and consultation—and the communications operation was shocking. The NHS is not safe in these politicians’ hands, and NHS England does far too little to oppose the nonsense.