The NHS maintenance backlog: rising costs and falling investment
About 5 mins
Key points
- The NHS maintenance backlog is the estimated cost of bringing NHS estates or buildings back to a minimum expected standard.
- The maintenance backlog more than doubled in real terms between 2015/16 (£6.4bn) and 2023/24 (£13.8bn), with the fastest growth in the highest risk category (urgent repairs to prevent catastrophic failure or disruption to clinical services).
- Since 2021/22, the backlog has grown by £2.1bn. Over the same period, investment to reduce the backlog fell by £707m in real terms, contributing to this growth.
What is the maintenance backlog?
The maintenance backlog is the estimated cost of bringing NHS estates or buildings back to a minimum expected standard. Buildings may fail to meet this standard because they are in a state of physical disrepair and/or fail to comply with certain safety regulations.
Any maintenance backlog is associated with some risk. This risk may take many forms, including patient harm, lower staff morale, legal enforcement notices and disruption to services. Each maintenance need is assigned a risk category by trusts (high, significant, moderate or low) based on a combination of the likelihood of an undesirable event or failure and the possible severity of the impact should the event occur. The NHS defines ‘critical’ risks as those that are categorised as ‘high’ or ‘significant’.
What has happened to the maintenance backlog?
Figure 1 shows how the real value of the backlog has changed over time, broken down by level of risk. The real value of the overall backlog, measured by the height of each bar, more than doubled between 2015/16 and 2023/24. Growth in the first half of that period was relatively slow, rising from £6.4bn in 2015/16 to £7.9bn in 2018/19. It then leapt to £10.8bn in 2019/20, a rise of almost £3bn in just one year. It has been suggested that this could in part be a consequence of the inclusion of issues related to reinforced autoclaved aerated concrete (RAAC) planks. The COVID-affected year of 2020/21 saw levels fall slightly, before then rising at a faster rate than they had prior to 2018/19. The most recent data indicate the backlog stood at £13.8bn in 2023/24. This is more than the total cost of running the NHS estate over the last financial year (£13.6bn).
Figure 1
The breakdown by risk level reveals that the backlog is not just larger but also carries an increasing degree of risk due to faster growth in riskier maintenance issues. The real value of the low-risk maintenance backlog barely changed between 2015/16 and 2023/24, while the values of all other risk categories more than doubled. The fastest growth was in the high-risk backlog, which grew from £1bn in 2015/16 to £2.7bn in 2023/24.
The backlog is highly concentrated in certain trusts: the 25 trusts (out of over 200) with the highest backlogs account for almost half (£6.6bn, or 48%) the value of the total backlog (£13.8bn).
How much progress has been made on tackling the backlog?
Figure 2 shows investment to reduce the maintenance backlog since 2021/22, split by critical and non-critical infrastructure risk. Between 2021/22 and 2023/24, the overall backlog grew by around £2.1bn, while investment in reducing the backlog fell by £707m. This implies that a reduced focus on addressing existing maintenance issues is contributing to the overall growth shown in Figure 1.
Figure 2
The provisional 2023/24 data suggest that most of the fall in investment to address the backlog since 2021/22 occurred in the most recent financial year. However, yesterday’s release reveals reporting errors from trusts, which when corrected show that the largest fall in investment was between 2021/22 and 2022/23, with a further reduction in 2023/24. Higher investment in the maintenance backlog in 2021/22 could have been COVID-related, but the subsequent falls still point towards a lack of prioritisation of addressing maintenance risks.
The fall in investment to reduce the backlog between 2021/22 and 2023/24 (of £338m, or 58%) was greatest for non-critical risks. The investment in critical infrastructure, where risks are regarded as high or significant, also fell by £369m, or more than a third (36%).
Overall capital investment in buildings and equipment has remained flat at around £5bn, meaning investment to reduce the backlog is making up a smaller share of total investment in 2023/24 than it did in 2021/22.
What does the future hold?
The Darzi review described the NHS as an organisation suffering from ‘capital starvation’, with capital budgets repeatedly raided to pay for day-to-day spending, all the while NHS estates are crumbling. The latest NHS Estates Return Information Collection is consistent with this finding. While staff numbers have grown since the pandemic, capital spending on buildings and equipment has been flat in real terms. Despite a continued rise in the maintenance backlog – particularly in those issues presenting the greatest risk to the NHS and its patients – investment to reduce that backlog has fallen. This is compounding the ongoing deterioration of the NHS estate and contributing to the rise in the maintenance backlog.
The government’s recent Autumn Budget announced a boost to the Department of Health and Social Care’s capital budget, a real-terms increase of £3.1bn by 2025/26, with £1bn of this earmarked for critical maintenance, repairs and upgrades. This is a welcome increase, but with a backlog that exceeds the total cost of running the NHS for the last financial year, significant and sustained capital investment will be needed to return the NHS estate to full working order. Achieving the government’s ambitions to improve NHS services will be difficult unless measures are taken to address the risks to productivity, quality of care and patient safety posed by the maintenance backlog.