Two years ago I wrote an article for HEJ titled ‘Badly maintained buildings can be a risk for all’,1 highlighting the significant concern around the level of backlog maintenance, and the potential for impact on patients and staff alike. At this point the financial position of backlog was £9.2 bn, with the critical infrastructure risk at £1.6 bn.2 So, what has changed? Over the past 10 years, the level of backlog maintenance (BLM) within the NHS England estate has increased from £4.3 bn to over £11.6 bn, with the critical infrastructure risk (CIR) increasing from £0.5 m to £2.4 m (see Table 1).
The chart shows that, based on the average trajectory, the 2023/24 backlog maintenance figures could reach £13.18 bn for BLM and £2.9 bn in CIR. This is an average growth of 13.6% overall for backlog, and 23% for CIR, all when inflation has been running at an average 2.92%. However, the figures are of themselves meaningless without being in context. The level of backlog maintenance is impacting three key areas – patient safety, staff productivity, and Trusts’ financial performance. This article synthesises work across finance, patient safety, and academia, to produce a broad picture on the impact of backlog maintenance within the NHS.
Financial impact
The impact on the financial position from backlog maintenance is not simply the cost to the estates budget to repair whatever failed. The wider impact to the Trust must be considered. Every time a theatre is closed it costs the Trust in question thousands of pounds in lost income and wasted staff hours. In addition, closed beds due to estates issues not only mean direct lost income opportunity for elective care, but also increase the pressure across the whole system, causing delays in admitting patients, and ultimately delays in ambulance handovers. The cost impact to the NHS across all Trusts over the f inancial year would run into tens of millions of pounds in terms of clinical disruption.
The backlog maintenance position is compounded by other factors:
Deterioration: The longer that investment is withheld from backlog maintenance, the more assets will continue to deteriorate. This increases the cost when a repair becomes a replacement. This deterioration is clearly seen in the 23% increase in CIR. While overall backlog increases at an average 11%-13% per annum, CIR has started to increase at almost double the rate. This can only be down to deterioration of assets.
Inflation: On top of the increasing cost due to asset deterioration, the cost of inflation plays a part in the increasing cost of backlog maintenance. However, using CPI inflation data, all else being equal, the cost of £4.30 bn cited in 2014/15 would today cost £5.33 bn, an increase of £1.03 bn.
Revenue impact: One of the biggest impacts on preventing backlog maintenance increasing is the estates revenue budgets. Many Trusts have seen an erosion of estates budgets over the decade. Trusts have been consistently hit with a 3-8% cost improvement (CIP) target, which has de-prioritised planned maintenance to focus on reactive repairs. An example of this is an Estates department which held a budget of £30 m in 2014, but an average CIP target of 5% would see their budgets almost half over a decade to £17.9 m. However, as an estate ages it requires both more planned maintenance, and more reactive maintenance, to ensure that it is functionally sound.
Patient safety incidents
In January 2021, the National Patient Safety team (NPSt) released data stating that clinical service incidents citing work and environmental factors in 2019/20 had doubled since 2011/12,3 amounting to over 115,000 incidents reported. As an estate infrastructure ages and clinical standards increase, greater funding is required to keep pace with planned maintenance and asset replacement to prevent failure and subsequent patient safety incidents.
Patient risk from infrastructure failure can originate from two main sources – active and latent. The active source is that of a primary cause/effect relationship, such as environmental factors which cause a patient to trip.4 These incidents have been captured within the 1,311,708 reported infrastructure incidents on the National Reporting and Learning System (NRLS) system since 2003.
The secondary, latent cause, is noted within the literature,5 but is not a subject that has been greatly explored. Environmental factors such as heat and noise caused by failing equipment have the effect of causing distraction, and subsequently harm, to patients,6,7 while, for instance, poor ventilation increases the likelihood of cross-contamination within hospitals.8 Equally, a failing environment or plant may be the primary cause of hospital-acquired infection in some instances, when all too often attention is drawn to the primary care giver and hand hygiene techniques as a simpler cause/effect explanation.9
However, it is not currently possible to quantify how many patients are being harmed. While there have been anecdotal reports, such as reports on the internet that 88 people were injured between 2015/16 and 2016/17 in hospital fires,10 or the report on unsuitable buildings causing inefficiency within the NHS,11 there has been no published work on the effects of NHS estate on patient outcomes. Likewise, there have been no systems put in place to track the impact of incidents on patient outcomes.
Delayed or cancelled treatment
In 2022/23, ERIC data cited indicated that more than 2,600 patients in acute hospitals had their treatment delayed or cancelled due to infrastructure issues at their hospital. While some aspects are minimal in terms of their impact (e.g. floods in Outpatients), other issues may amount to months of disruption – such as when waiting for new parts for air-handling units. The harm that this delay in treatment is causing is rarely linked to specific incidents. However, the level of disruption and impact on patients can be noted directly from clinicians. At the end of 2022 the British Medical Association published a survey of all its members,12 which highlighted 11 key findings, including:
43% of doctors surveyed told the BMA that the condition of their workplace has a negative impact on patient care.
38% of doctors answering the BMA’s 2022 estates and IT survey said the overall physical condition of their workplaces was ‘poor’ or ‘very poor’.
Crumbling buildings and infrastructure often force wards and beds to close, compounding a wider lack of space across healthcare estates, and contributing to ever-expanding waiting lists.
While the NHS does not collect root cause analysis data on all patient safety incidents, there is sufficient evidence to suggest that there is an ongoing clinical impact on a large cohort of patients due to the level of backlog maintenance.
Academic
When looking at patient harm research within the built environment, there is a strong tendency to focus on the design rather than the management of the estate. It has been established that good evidence-based design (EBD) can significantly improve the environment in which patient care is given and, by extension, improve health outcomes. However, the current impact of EBD within the NHS is limited due the lengthy replacement cycle involved in embedding EBD into the NHS.
There is a small body of evidence that recognises the importance of the support role that management and maintenance of the built environment plays to clinical services and the patient. There is a general acceptance that maintenance is crucial in healthcare settings, and that the failure of key infrastructure systems – heating, water, ventilation, electrics – could have significant impact on patients.13 However, the lack of research into the impact of failing infrastructure is hard to assess,14 due to the source of the impact quite often being latent. There is a sufficient body of evidence to indicate that an aged estate is having a detrimental effect on patient health,15 but this is often couched in clinical research, with estates impact being incidental rather than the focus. In 2020/2021, 123 people lost their lives at work. In the same period an estimated 309 patients lost their lives in English NHS hospitals due to infrastructure failings.3 The impact of latent harm is currently unknown. It has also been argued that poor infrastructure has a negative effect of staff recruitment,16,17 which in turn could have a direct impact on the patient if the facility was under-resourced.
There are many isolated studies which demonstrate the devastating effect on patients when estate fails. Whether it is the increased deaths seen during COVID-19 due to insufficient and failing mechanical ventilation,18 the review of MRSA and C. difficile transmissions attributable to restricted natural ventilation and poor mechanical ventilation, or a meta study in 2007 which noted the death of 12 patients, mostly linked back to failings within the estates infrastructure, the studies clearly demonstrate how the Estates department is not only intertwined with the clinical teams, but can be the source of significant impact to both patient and clinical services. Such outbreaks ‘require the co-ordinated efforts of clinicians, nurses, pharmacy and hospital engineers, working in collaboration with the hospital infection control team’.19
Making a change
If the level of backlog maintenance and CIR continues to grow over the next five years at the same rate seen over the preceding 10, in 2028/29 the level of backlog will have risen to £25 m green book value, with over one third being classified as critical infrastructure risk. The risks that this level of backlog maintenance carries could be catastrophic for the patients, staff, and the reputation of the NHS. So, something needs to change.
Firstly, while the green book value quoted within ERIC is a common cost baseline, it hides a significant cost. Stating that a Trust has £100 m of backlog maintenance is inaccurate, as it omits so many costs. While there is no agreement whether the green book cost should be uplifted by 70%, 80%, or indeed 100%, one thing is certain – the £11.6 bn of backlog is closer to £20 bn. Implementing an agreed uplift for all Trusts will give a far better indicator of the cost impact than simply using green book value.
The next thing that needs to occur is significantly more research into the impacts of the estate, failing or otherwise, on patients and staff alike. Only by truly understanding how the built environment interacts with the users of the facility can we make meaningful changes. The author is currently undertaking two studies which will support this understanding.
The first is to retrospectively review four million patient records to understand how failures within the estate infrastructure are impacting patients, and to what extent of harm. The study has been training the large language model, ‘BERT’, to recognise estates-related factors within the clinical reports. It is anticipated that the results of the study will be available by the end of 2024.
The other study seeks to understand the importance of backlog maintenance among key executives and senior managers in NHS acute Trusts. The study is looking at why backlog maintenance is not getting the level of funding it requires over other projects, and whether the potential risk inherent within the backlog maintenance is being articulated sufficiently. This study should conclude early in 2025.
Summary
There is a lot of pressure on NHS Trusts to reduce waiting lists, to tackle queuing ambulances, and to continue to provide an elevated level of care and professionalism. However, the environment in which the patient is treated is as important to the health of the NHS as any other factor. While not investing in the infrastructure supports the immediate budget pressures, the long-term effects and cost to rectify the issues will spiral. More research into all aspects of the healthcare environment will support both the understanding of its interaction with patients and staff, and the importance of the infrastructure. The infrastructure is the second biggest asset the NHS has. For the sake of the future of the NHS, we need to start investing and caring for it a bit more.
David Jones
David Jones, the director of Estates, Facilities and Capital Development at the University Hospital of Southampton, has worked in senior positions across the NHS for 16 years, and – prior to this – in the commercial and public sectors. A Fellow of IHEEM, he has an MBA from the University of Surrey, and is currently in the fourth year of working towards a Ph.D. at the University of Southampton. His research is focused on understanding the causal relationship between backlog maintenance and patient safety incidents within the acute sector of NHS England – ‘to set a foundation for greater study and understanding of the impact of the built environment on the patient journey’. For more information, visit www.dpjones.uk
References
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