INSIGHT: A prescription for change: rethinking strategies to address NHS backlog maintenance

There are two dreaded words that bring an almost universal shudder to those working in estates across the NHS – backlog maintenance. Recent reports have highlighted the cost of backlog maintenance is now approaching an eye watering £12 billion across the NHS acute estate alone. A figure that has almost doubled since 2018/19 when it stood at a not insignificant £6.8 billion.

Perhaps this is not surprising when you consider that of the 1200 operational sites which are owned and operated by NHS Trusts across England, 45% is now at least thirty years old with almost a third built prior to 1975. To put this in perspective for a readership of varying ages, that’s two years before Queen Elizabeth II celebrated her Silver Jubilee, ten years before Band Aid and over thirty years before the iPhone was first released…

Year on year, pre-1990 NHS estate is increasingly and relentlessly becoming unfit for a growing population with changing health needs. But while the value of ‘high risk’ designated backlog increased by 31% during 2022-23, NHS investment made towards addressing ‘high risk’ maintenance actually fell in the last 12 months from £1.41bn to £1.38bn.

And so, two things are clear. Firstly, a lot of the NHS estate is old and in desperate need of repair but more importantly, the current strategy clearly isn’t working and does not represent a sustainable way forward.

Rather than seeking substantial capital to invest in old buildings which are well beyond their sell-by date, we should instead be focusing on investing in the required estate changes to achieve a flexible, modern and integrated service models at all levels – primary, community and acute care – and in making service delivery as efficient and efficient as possible, helping not only to improve patient experience and outcomes but also helping contribute towards retention of an increasingly frustrated and disillusioned workforce.

Pre-1990 estate with high backlog maintenance costs should be reviewed as a priority to understand whether it is better value for money to retain and invest in the asset or to instead assess if the services it is housing can be moved into a community setting – whether that be estate owned by NHS Property Services and/or LIFT, Local Authority or Private Sector.

At present, taxpayer and NHS budget money is paying for the upkeep void and/or underutilised community healthcare space with an estimated 20,000m² in just London alone. Utilising these clinical spaces more effectively fulfils a triple aim by ensuring that void space currently being paid for by the NHS system actually provides value for money, patients have access to services in their community setting rather than travelling to an acute site and less investment is required to maintain acute estate which is unfit for purpose.

There are some examples across England of this model coming to light but there is significant scope to develop further opportunities through a partnership approach. After all, no Trust or community provider can address the scale of NHS estates challenges by working in isolation. Integrated Care Systems have to play a key role in achieving change by acting as both facilitator and arbiter, reviewing estate budgets from Trusts and providers across their system collectively and rallying for synergies and strategies which can help both manage the overall levels of investment required while also realising performance improvements and health outcomes.

Relying on ERIC data to identify capital investment needs can only result in an NHS which will continually be chasing its tail in the management of its infrastructure. If £12 billion is to be spent on estates, it should be spent to create long-lasting change and ensure value for money for patient, staff and systems across the country.

About the author

Liam Sayers is Associate Director, Operations for Archus in London. Alongside in-depth expertise in the writing and delivery of business cases for NHSE and Local Government clients, he is passionate about the joining-up of local government and healthcare services to create more flexible and collaborative models which improve access to health, social and mental health services in the community.