NHP0008

 

 

Written evidence submitted by the British Medical Association

 

 

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

 

Executive Summary

 

1.1   The BMA welcomes the opportunity to respond to the Public Accounts Committee’s inquiry into progress made delivering the Government’s new hospitals programme (NHP).

1.2   This response draws on the findings of the BMA’s 2022 estates and IT survey, which exposed serious failings in the current state of the healthcare estate, and the findings of the NAO’s report on the progress of the NHP.

1.3   It sets out our concern over the ambition, scope and delivery of the NHP as well as recommendations for further action the Government must take to make the necessary improvements across secondary, primary and mental health care estates.

1.4   These include:

-          Long-term, ring-fenced capital investment to ensure patients and staff have access to safe facilities.

-          Immediate investment to tackle the significant and growing maintenance backlog.

-          A comprehensive audit of the state of the healthcare estate and the involvement of doctors and other healthcare professionals in identifying where problems exist and how best to address them.

-          Design, layout and capacity improvements to help address delays in patient care, ensure there is space for training and improve staff wellbeing to ensure doctors are able to deliver the best possible care to patients.

-                                  Urgent action and investment to ensure the estate is capable of delivering adequate IPC measures is essential to protecting doctors and patients from harm and improving wellbeing by reducing anxiety associated with the heightened possibility of contracting COVID-19 or other infectious diseases.

-          A focus on ensuring that the delivery of the NHP and wider improvements in the healthcare estate support efforts towards achieving net zero and meet the NHS Net Zero Standard.

1.5   We urge the Committee to utilise the inquiry to question the Government on what it is doing to address these recommendations.

 

Government progress delivering the New Hospitals Programme

 

2.1   High-quality estates are essential to deliver safe healthcare services, ensure those that need care get it, and to protect the health and wellbeing of staff, but currently far too many estates are not fit for purpose.

2.2   An alarming 38% of doctors responding to the BMA’s 2022 estates and IT survey reported that the overall physical condition of their workplaces is poor or very poor, whilst 43% told us that the condition of their workplace has a negative impact on patient care.[1] Meanwhile, the maintenance backlog has reached a staggering £14bn across the UK and £10.2bn in England (see figures 1 & 2 in appendix).  Urgent action is needed to improve capacity, deliver safer buildings, safer care, and safer working lives for doctors.

2.3   The 2020 New Hospitals Programme demonstrated Government recognition of the need to improve the existing estate but, as identified in the NAO report[2], progress on delivering this has been too slow, lacked the necessary funding commitments and it is disappointing that the Government will not now meet its initial target.

2.4   The scale of the programme was also quickly discovered to be far more modest than advertised, with most of the projects being refurbishments. NAO analysis found that under the broad definition of a ‘new hospital’ used by DHSC, only 11 of the 40 projects represented whole new hospitals and one did not meet the DHSC’s definition at all.[3]

2.5   Construction of some of the new builds has also been delayed[4] and only three of the eight schemes identified in cohort 1 of the NHP had been built by June 2023. There have also been delays in the competition of the design of Hospital 2.0 and it is now not expected to be completed until May 2024, limiting the progress on delivering cohort 3 of the programme. The delay to the Hospital 2.0 design may also be preventing prospective applicants to the NHP from fully understanding DHSC’s expectations for future hospitals, limiting their capacity for forward planning.

2.6   The Government’s May 2023 update on the programme gave necessary certainty, funding and direction to the delivery of the programme, but re-set the parameters of the programme watering-down its initial ambition.[5] As identified in the NAO report, even by the broad definition Government used in 2020, it will now only deliver 32 “new” hospitals by 2030.[6]

2.7   The minimum funding HMT has indicated it will attach to the scheme (£18.5bn for the period 2025-26 to 2030-32) is also less than the £21.3bn requested, resulting in the NAO warning that these affordability challenges risk further delays to schemes or a reduction in the scope of future hospitals. The Government in its May re-set of the scheme stated that over £20bn was now expected to be spent on the scheme, though this is subject to future spending reviews and the review and agreement of final business cases.

2.8   Given the significant impact of lack of space within the hospitals estate on both the delivery of patient care and staff wellbeing, such as the provision of staff break out areas, it is further concerning that the NAO has warned that the minimum variable product (MVP) version of Hospitals 2.0, which DHSC is considering will result in hospitals that are too small. A chronic lack of space and the inflexible layouts of many buildings have also made social distancing a challenge, contributing to the spread of COVID-19 and other infections.[7] [8] There is a clear need for additional bed capacity in the NHS and the BMA endorses the RCEM’s (Royal College of Emergency Medicine) view that England is currently over 10,000 beds short of the number needed, so it is critical that future hospitals are able to accommodate these beds and provide sufficient capacity to meet demand.[9]   

2.9   The condition of the healthcare estate has a significant impact on emissions and the NHS’ capacity to support efforts towards net zero. The Government must also therefore urgently address the NAO’s warning that under the MVP approach there is a risk that new hospitals will not be fully compliant with the new NHS standard.[10]

 

Impact of the condition of the estate on patients and doctors

 

3.1   Research, published in our 2022 report ‘brick by brick’ exposed the dire condition of the healthcare estate across the UK and the impact underinvestment is having on the safety and wellbeing of doctors and their patients. An alarming 38% of doctors answering the BMA’s 2022 estates and IT survey reported that the overall physical condition of their workplaces was poor or very poor. Critically, 43% of doctors surveyed told us that the condition of their workplace has a negative impact on patient care. Examples included crumbling buildings and infrastructure forcing wards and beds to close, compounding a wider lack of space across healthcare estates and contributing to ever-expanding waiting lists.

3.2   This lack of space frequently means that doctors and staff also lack any private workspaces in their places of work, impacting not only their ability to carry out clerical tasks, but, critically, their capacity to hold important conversations with patients and their families privately. In response to our 2022 estates survey, doctors noted that the lack of private space also impacts patient confidentiality and, by extension, the quality of patient experience.

3.3   Given the immense pressures currently facing the UK’s health services and the underlying workforce crises compounding them, it is unacceptable that doctors must go to work caring for patients in such poor conditions. Doctor morale is at an all-time low due to feeling undervalued, underpaid, and overworked – when the physical environment in which they work is equally neglected. More importantly, there are serious safety considerations that can no longer be ignored. Examples we have heard from doctors include sewage leeks and burst waste pipes exposing staff and patients to risk of infection and electrocution.[11]

 

Patient safety

 

3.4   In 2021-22, NHS England reported 5,348 clinical incidents caused by estates and infrastructure failure, over double the number seen in 2016-17 – clearly illustrating the scale of the impact poorly maintained and dated estates, compounded by a lack of investment, have on patient care.[12]

3.5   The profound risk to both patients and doctors from unsafe estates was further uncovered by an FOI conducted by the Liberal Democrat Party, which uncovered hospitals with broken fire alarms and that more than 115 chemical leaks occurred in NHS hospitals in 2022.[13]

3.6   Many hospitals are also facing IPC vulnerabilities, as exposed by the COVID-19 pandemic, which place both staff and patients at risk of infection. During the COVID-19 pandemic, this – alongside a lack of access to RPE (respiratory protective equipment) meant the medical profession and patients were inadequately protected against the virus, contributing to high levels of anxiety, illness – including long COVID – and tragically, deaths.[14] These problems persist with nearly 7 in 10 doctors in 2022 reporting that they felt their place of work would not allow for appropriate ventilation and IPC measures in the event of a future wave of COVID-19 or another pandemic.[15]

3.7   The survey also found that problems within primary care and GP practices with 26% of respondents working in primary care stating that the building in which they work is in a poor or very poor state. As with hospitals, some GP practices have also faced decline due to a dearth of capital funding or investment across the UK’s health systems, with too little support made available to practices to expand or make improvements.

3.8   Inadequate estates present a particular risk for mental health services which have specific requirements, such as ligature points[16] or potential escape routes. For example, doctors have reported patients that could be at risk of harming themselves leaving through smashed windows and faulty door alarms.[17]

3.9   It is essential that the greater focus on mental health services and funding in recent years is extended to include the facilities in which they are offered, too. The Royal College of Psychiatrists has called for the construction of six new mental health hospitals[18] and Simon Wessely’s review of the Mental Health Act has called for new capital investment to modernise the mental health estate, noting the importance of the inpatient environment in enabling people to get better.[19]

3.10           The Government has committed to delivering three new mental health hospitals: the Surrey and Borders NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust and Mersey Care Foundation Trust. Whilst the recognition of the need to improve the quality of the mental health estate is welcome, these programmes do not go far enough to address the extent of improvements needed. The programmes, announced in 2022, were committed to outside of the New Hospitals Programme and therefore previously not included in the commitment to build 40 new hospitals. As such, the subsequent inclusion of these programmes has contributed to the NAO’s analysis that only 32 new hospitals will now be delivered by 2030 as part of the NHP.

 

BMA recommendations:

3.11           It is clear the New Hospitals Programme is not ambitious enough in scope to address the multiple safety critical issues posed by the NHS estate.

3.12           Further action and the prioritisation of substantial investment to address the state of hospitals across the UK is essential to protect the safety and wellbeing of doctors and patients, as well as ensure the estate has capacity to meet patient demand.

3.13           This must include long-term capital investment to address the growing maintenance backlog, which has reached a staggering £14bn across the UK and £10.2bn in England (see figures 1 & 2 in appendix).  This funding must be ring-fenced so that it cannot be drawn from to cover deficits elsewhere in the NHS, as has been done previously,[20] further exacerbating the maintenance backlog. 

3.14           To ensure money is spent where it is most needed a comprehensive audit of the state of the UK’s healthcare estate is also required. This must include drawing on the expertise of doctors and other healthcare professionals who are best placed to identify where problems in the current estate exist and how best to address them.

3.15           Given the safety critical threat posed by poor estates, the BMA also recommends that UK regulators with a remit covering healthcare estates should, as part of their regular assessments, consider the  quality of those estates and the care provided within them as a result.

3.16           The development of the MVP version of Hospitals 2.0 must ensure that hospitals have sufficient physical capacity to meet demand, are contributing to the green agenda, allow for appropriate infection prevention and control, and that all doctors have access to quiet, comfortable, office spaces where they can work without interruption, and discuss confidential matters in private.

 

Impact of limited space on doctors and patients

 

Patient safety and waiting lists

 

4.1   If doctors are to deliver care to the highest standard, they must have the space to do so, including modern and sufficient clinical spaces to treat ever-increasing numbers of patients. Worryingly, the most recurrent complaint about the healthcare estate in the BMA’s estates survey[21] was a lack of space. Doctors have reported having to turn store cupboards into clinical spaces, removing coffee rooms and treating patients in corridors. As warned by bodies including the Royal College of Emergency Medicine, using such spaces to treat patients presents a potential risk to patient safety.[22]

4.2   This chronic lack of space contributes to significant delays to patient care and means that many hospitals do not have enough beds where patients can be seen or treated. Compared to other G7 nations, the UK has the lowest number of beds per 1,000 inhabitants.

4.3   Whilst one of the potential solutions to the shortage of both beds and space is the use of ‘virtual wards’, these are dependent on access to high quality IT and digital infrastructure the NHS does not yet have, and their efficacy remains unproven.[23]

4.4   Increased capacity within the NHS estate is also essential to helping address the NHS workforce crisis by providing space for training. The vast majority (84%) of respondents to the BMA’s estates survey reported difficulties finding spaces for educational or training purposes at their place of work, with one in three (35%) saying this is significantly difficult.[24]

 

Wellbeing

 

4.5   Beyond these immediate safety concerns, the design, space and layout of hospitals also has a significant impact on doctors’ and patients’ wellbeing.

4.6   As established by the BMA’s Fatigue and Facilities Charter[25], it is vital that doctors have access to high quality rest spaces to enable them to deliver safe care. However, many doctors do not have access to a suitable break space, an issue exacerbated by the chronic lack of space in the estate. Over a third of respondents to the BMA’s estates survey (38%) said that the availability of break space was having a ‘negative’ or ‘significantly negative’ impact on their wellbeing at work.

5                                                                      The estate is also currently incapable of delivering adequate IPC (infection prevention and control), a serious shortcoming given the continuing threat of COVID-19 and other infectious conditions. These factors are proven to have contributed to the spread of COVID-19 and other infections, contributing to high levels of anxiety, illness – including long COVID – and, tragically, deaths. In 2022, two years on from the outset of the pandemic, nearly 7 in every 10 (67%) respondents to our survey felt that their place of work would not allow for appropriate ventilation and IPC measures in the event of a future wave of COVID-19 or another pandemic: about 36% were not at all confident, and 31% said they were not very confident. Urgent action and investment are needed to remedy this crisis before it deepens and puts doctors and patients at even greater risk of harm.[26]

Equality and environmental considerations

 

5.1   Addressing accessibility concerns and lack of access to spaces for breastfeeding, pumping, and religious activities, must be key considerations for Government in delivering the New Hospitals Programme. This is vital to improving both safe access for all patients and staff as well as improving the wellbeing and equity for doctors and patients who require such spaces.

 

BMA recommendations:

 

5.2   An emphasis on increasing the capacity of the NHS estate is vital for patient safety, to address delays in patient care, help grow the NHS workforce and in improving staff wellbeing to ensure doctors are able to deliver the best possible care to patients. We therefore urge the Government to act on the NAO’s recommendation that it urgently re-examine the assumptions underpinning the MVP version of the Hospital 2.0 design, in particular that they identify and address any proposals likely to result in future hospitals being too small.

5.3   In delivering the NHP, Government must ensure break spaces are made available in the short-term, and that all new buildings and expansions include guaranteed break spaces compliant with guidelines set out in the BMA Fatigue and Facilities Charter[27] and Junior Doctor wellbeing checklist,[28] designed with the direct input of doctors.

5.4   Building staff capacity must go hand-in-hand with building estate capacity to ensure there is the space to both train and accommodate new staff. Any delivery of the review of healthcare estates called for by the BMA must therefore include assessments of the availability and quality of training space. Any nationally mandated increase in primary care staffing within GP practices must also be accompanied by additional funding for premises expansions and improvements, to properly accommodate additional staff.

 

Sustainability

 

5.1   The climate crisis poses a significant and growing threat to public health; the World Health Organisation estimates that between 2030 and 2050, climate change will be responsible for around 250,000 additional deaths a year.[29] Worryingly, these effects on public health are already visible; in the UK, air pollution alone is already responsible for up to 36,000 excess deaths a year.[30] For this reason, the BMA has declared a climate emergency and called for the UK to achieve Net Zero carbon emissions in the shortest possible amount of time.

5.2   It is crucial that the Government considers the impact of the healthcare estate on emissions and its capacity to support efforts towards net zero. The condition of the estate plays a major part in the sustainability of health service organisations and capital investment to make buildings more energy-efficient – via improving insulation, modernising heating systems, and switching to renewable energy sources and modes of transport – is required (and could save costs longer term). An FOI request carried out by the BMA in December 2021 found that some progress has been made against targets to make UK healthcare estates greener, but that this progress seems to have stalled since 2019. There is significant variation between performance of individual trusts and health boards in relation to sustainability. It is clear that a lack of capital funding has played a significant role in this; 55% of trusts or health boards have reported having no capital funding to improve the efficiency or sustainability of their estates.[31]

5.3   The new NHS Net Zero Building Standard published as part of NHSE’s plan to deliver the first net zero health service by 2045 is a promising step towards a sustainable health service. It is concerning therefore that the NAO has concluded that under the MVP approach, there is a risk that new hospitals will not be fully compliant with the new NHS standard.[32]

 

BMA recommendations

5.4   The BMA urges the Government to act on the NAO’s recommendation that it urgently set up a process for reviewing MVP hospitals’ progress against the net zero building standard.

5.5   Beyond this, it is vital that government provide organisations with ringfenced capital funding to improve the sustainability of estates.

 

August 2023

 

 

 


Appendix

 

Figure 1

 

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Figure 2

 

A graph of a cost reduction

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[1] BMA 2022 Estates and IT survey

[2] NAO (July, 2023) Progress with the New Hospital Programme

[3] Ibid

[4] HSJ (July 2021) Shake-up of ‘new hospitals’ project after construction capacity concerns

[5] DHSC Press Release (May 2023) Five major new hospitals to be rebuilt as part of over £20bn new hospitals infrastructure programme

[6] NAO (July, 2023) Progress with the New Hospital Programme

[7] Dietz L, Horve PF, Coil DA, et al (2020) 2019 novel coronavirus (COVID-19) pandemic: built environment considerations to reduce transmission. Msystems 5: e00245–20

[8] Fadaei, A. (2021). Ventilation Systems and COVID-19 Spread: Evidence from a Systematic Review Study. European Journal of Sustainable Development Research, 5(2): em0158

[9] RCEM (May 2022) Beds in the NHS

[10] NAO (July, 2023) Progress with the New Hospital Programme

[11] BMA (December 2022) https://www.bma.org.uk/media/6579/bma-infrastructure-1-report-brick-by-brick-estates-dec-2022.pdf

[12] NHS Digital, ERIC (Estates Returns Information Collection) 2021/22

[13] Liberal Democrat Party Press Release (August 23) England’s Hospitals are crumbling

[14] British Medical Association (2022) BMA Covid Review 1: How well protected was the medical profession from COVID-19?

[15] BMA (December 2022) Building the Future – Brick by Brick: The case for urgent investment in safe, modern, and sustainable healthcare estates – see Figure 4, pg. 13

[16] National Audit Office, (February 2020) Review of capital expenditure in the NHS

[17] BMA (December 2022) Building the Future – Brick by Brick: The case for urgent investment in safe, modern, and sustainable healthcare estates

[18] The Guardian, (Feb 2022) Call for six new mental health hospitals in England as buildings ‘crumble away’

[19] Simon Wessely (Dec 2018) Modernising the Mental Health Act: Increasing choice, reducing compulsion

[20] In the five years to 2018-19, the Department of Health & Social Care (DHSC) and NHS England diverted £4.3 billion of planned capital spend to fund day-to-day spending.

[21] BMA 2022 Estates and IT survey

[22] Health Service Journal (Nov 2022) NHSE issues fire risk warning over ‘corridor care’

[23] NHS England (Aug 2022) Next steps in increasing capacity and operational resilience in urgent and emergency care ahead of winter

[24] BMA 2022 Estates and IT survey

[25] BMA (July 2018) Fatigue and Facilities Charter

[26] BMA 2022 Estates and IT survey

[27] Ibid.

[28] BMA (May 2021) Junior Doctor Wellbeing Checklist

[29] World Health Organisation, Climate Change. (Accessed August 2023)

[30] Office for Health Improvement & Disparities (February 2022) Air pollution: applying All Our Health.

[31] BMA 2022 Estates and IT survey

[32] NAO (July, 2023) Progress with the New Hospital Programme