Public Accounts Committee inquiry on the New Hospital Programme: submission from NHS Providers

• Trusts are concerned that further delays to the New Hospital Programme may undermine staff morale and stakeholder confidence. Trust leaders were bitterly disappointed by the outcome of the government’s review of the New Hospital Programme (NHP), which pushed many schemes beyond the original 2030 deadline. Further delays risk normalising unacceptable working conditions for staff, with outdated buildings remaining in use far longer than planned. Trusts are calling for greater transparency on how schemes have been prioritised and how delivery timelines have been determined.
  
  
• Repeated delays are forcing trusts to operate end-of-life buildings for far longer than intended, increasing legal and compliance risk. Some NHP schemes are now not expected to begin construction until 2039 – more than nine years later than originally planned – meaning hospital buildings may remain in use more than two decades after being deemed end-of-life. Trusts are incurring significant additional costs to keep unsafe and outdated buildings operational. Trusts are seeking clear guidance from the NHP on how to manage the legal, regulatory and compliance risks associated with operating from facilities that no longer meet modern standards or may be structurally compromised.
  
  
• Inflation is adding significant costs to schemes the longer they are delayed. While trusts welcome the £24bn long-term funding settlement for the NHP, it is below the government’s own estimated cost of completing Wave 1 and Wave 2 schemes, indicating that some projects may not be delivered before the agreed funding envelope runs out in 2035. Ongoing delays are adding significant cost, with construction inflation increasing costs for some schemes by an estimated £20–30m per year, alongside substantial spending on maintaining deteriorating buildings and undertaking repeated safety and compliance reviews. Trusts would welcome a review of whether expediting delivery of some schemes, particularly smaller projects, could offer better long-term value for money.
  
  
• The Hospital 2.0 design must be sufficiently future-proofed to deliver hospitals that meet the changing health needs of the population. The final Hospital 2.0 design must be underpinned by assumptions that are realistic and can adapt to accommodate changing models of care and advances in technology. Trusts remain concerned that cost-driven decisions may compromise the clinical value that future hospitals provide.

The NHS provider sector (acute hospitals, mental health, community and ambulance trusts) has a vital role in creating a healthy, equitable and productive society. While there has been a welcome rise in capital investment in recent years, trusts continue to face significant difficulty in accessing sufficient capital investment to deliver critical repairs, update antiquated equipment and invest in transforming their estate. 

The 2024/25 Estates Returns Information Collection (ERIC) data (NHSE, 2025) – published in October 2025 – highlights that trusts continue to manage significant levels of risk across their estates:

• Over 2024/25, the maintenance backlog rose to a record-high £15.9bn - up by £2.1bn from 2023/24 (a 15% rise).
  
  
• Despite investment to reduce the maintenance backlog increasing by 14.5%, the total increase in the size of the maintenance backlog (£2.1bn) continued to be higher than the total amount of investment trying to reduce the backlog (£1.02bn).
  
  
• The proportion of the backlog relating to high or significant risk now stands at 57% (£9.1bn) – this is an increase of £1.5bn compared to 2023/24.
  
  
• The total number of estates and facilities related incidents increased by over 8% to 8,653 in 2024/25.
  
  
• Approximately 40% of the 2024/25 maintenance backlog is accounted for by trusts which have schemes under the NHP.

At present, 42% of NHS facilities were built before 1985 and 14% of facilities predate the NHS’ establishment in 1948 (UK Parliament, 2024). Ageing infrastructure poses significant challenges for trusts in meeting modern healthcare standards or developing the 21st century services that trust leaders and government are committed to. Given the condition of the estate, many trusts are forced to prioritise limited operational capital budgets on maintenance work over longer-term strategic investment.

Impact of continued delays

Trusts leaders involved in the NHP were bitterly disappointed at the outcome of the government’s review of the programme, which delayed many of the schemes beyond the original 2030 completion deadline. Although the government’s approach to be upfront and honest about when trusts can realistically expect to begin construction was welcome, the outcome of the review understandably caused significant frustration. Trusts would have welcomed a more transparent approach to outlining how the revised implementation plan has prioritised schemes and determined the speed at which they can be delivered.

Further delays to the NHP have worsened staff morale and stakeholder confidence, with some outdated buildings likely to stay in use far longer than planned. Trust leaders have shared that there is a risk of normalising unacceptable working conditions for staff. Trust leaders are finding it much more difficult to sustain stakeholder engagement due to the lack of transparency on when projects are due to be completed. There is a risk that confidence in the NHP amongst local stakeholders (e.g. patients, local partner organisations, MPs) is being eroded and the impact this may have on trusts’ relationships with local partners and communities.

A number of NHP schemes have faced repeated delays, with some schemes now projected only to commence construction in 2039 – more than nine years later than the original programme completion date. In some cases, hospital buildings are set to be in use more than two decades after the infrastructure was deemed end-of-life. Indeed, the National Infrastructure and Service Transformation Authority’s (NISTA) annual report outlines that the NHP is not expected to be completed until April 2046. 

Trusts involved in the NHP would welcome clear guidance from the NHP on how to successfully manage any legal or compliance risks as a result of operating from facilities that no longer meet modern infrastructure standards or may be structurally compromised.

As a result of continued delays, NHP trusts have had to stand down local project teams as a result of insufficient funding being available. Trust leaders feel this is a short-sighted approach and will lead to significant gaps in project knowledge and institutional memory which will be difficult to replace when these schemes move towards the delivery phase.

Funding and long-term financial pressures

Trusts welcomed the government’s decision to commit £24bn in funding for the NHP over the next decade (to the end of 2034/35), along with announcing multi-year capital budgets which offers trusts involved in the programme greater certainty over their capital allocations. Additionally, ringfencing funding for the NHP over the remainder of the Spending Review period should ensure that funding cannot be reallocated to support pressures in other areas.

Despite trusts welcoming the long-term funding settlement for the NHP, it is worth noting that the £24bn funding settlement over the next decade is below the government’s own cost estimate for completing Wave 1 and Wave 2 schemes – indicating that some of these schemes will not be completed before 2035.

Delays to delivering the programme do not come without a cost. Trusts involved in the programme have reported that inflation is effectively increasing the prospective cost of their schemes by approximately £20m - £30m per year. This is in addition to the large sums trusts are incurring in maintaining deteriorating buildings and the numerous building surveys and critical infrastructure reviews required to ensure patient safety while operating from unsuitable buildings. Trusts would welcome government reviewing whether expediting delivery of some schemes – especially smaller schemes – may actually present better value-for-money over the long term. 

Trusts are concerned about future financial pressures as a result of operating from new facilities - new hospitals typically incur higher operating costs. While assurances from the NHP have been given that the revenue impact will be neutral, many trust leaders remain sceptical about the feasibility of this promise. Energy-efficient systems, advanced digital infrastructure and expanded facilities introduce additional maintenance and staffing costs. Without dedicated revenue support to offset these pressures, trusts risk facing significant financial strain in the future, potentially compromising service sustainability and overall financial performance.

Hospital 2.0 standardised design

Trust leaders emphasise that new hospitals must be designed to be future-proof. The NHP should align with the ambitions of the 10-year health plan (10YHP) by delivering facilities that set a benchmark for modern healthcare - flexible, digitally enabled and patient-centred. This includes incorporating integrated diagnostics, smart technologies and sustainable infrastructure to support evolving models of care, enhance patient experience and enable staff to work more efficiently.

The NAO’s original report on the NHP – published in July 2023 – outlined a number of risks with the assumptions underpinning the minimum viable product version of the Hospital 2.0 design – for example, the assumptions made on the proportion of care to be delivered in out-of-hospital settings in future and sustainable levels of bed occupancy. It is essential that the assumptions underpinning the final Hospital 2.0 design are realistic and future-proofed to accommodate changing models of care and advances in technology to ensure they meet the expectations of the public. The Hospital 2.0 design should be aligned with the vision set out in the 10YHP.

Trusts involved in the programme still have some concerns that cost-driven decisions may compromise the clinical value that future hospitals can provide. Trusts understand that all schemes must be affordable, but there is a risk that cost constraints could limit the scope of the scheme, and in turn the potential benefits to their local communities.

Trust leaders remain concerned that applying rigid Hospital 2.0 standards to constrained or heritage sites poses significant challenges. Historic buildings often cannot accommodate the full specification without costly adaptations, creating financial and practical barriers. Additionally, business cases for popular features, such as single rooms, are often underdeveloped with inconsistent evidence on their benefits, making it difficult for trusts to justify the additional expense. 

Reinforced Autoclaved Aerated Concrete (RAAC)

Trusts understand and agree with the government’s decision to expedite replacement of the hospitals where RAAC planks are extensively used. Originally designed for a 30-year lifespan, many have now been in service for over 50 years - well beyond their intended durability. To prevent sudden roof collapses, trusts are resorting to costly interventions such as full roof replacements or installing secondary supports like scaffolding and steel props. Despite these mitigation measures, concerns about staff and patient safety remain high. Emergency monitoring regimes, temporary closures and restricted access zones are common across trusts, adding operational complexity and cost without fully eliminating risk.

As the 2023 NAO report outlined, a report carried out by Mott MacDonald advised that the most at-risk hospitals needed to be replaced by 2030, but the revised timeline set out by the implementation plan suggests construction on some RAAC schemes may not start until 2028 or 2029. The government must do all it can to ensure that RAAC schemes will be replaced by 2030 so the trusts involved can have full confidence that they are able to provide a safe environment for staff and patients. 

RAAC has attracted significant government attention because of its urgent safety implications. However, trust leaders emphasise that other buildings suffering severe structural degradation (but not due to RAAC), often patched up with makeshift reinforcements, receive far less focus and funding, despite similar levels of risk. National bodies should work closely with trusts to manage significant infrastructure risk sitting across the NHS estate.

Trust engagement with the NHP team

Although trusts involved in the NHP acknowledge that communication and engagement with the national NHP team has improved this year - particularly with stronger engagement on Wave 0 and Wave 1 schemes - interaction with the national team continues to be inconsistent. Trust leaders want to see more transparent, timely communication on critical issues such as business case development, funding approvals, enabling works and how the NHP aligns with wider transformation priorities, including digital-first care and net-zero estates. Inconsistent communication has historically created uncertainty, leaving trusts unclear about next steps and creating challenges for local teams and contractors in explaining progress to local stakeholders, staff and the wider public.

Trusts continue to experience frustration due to fragmented review processes, with materials frequently subjected to multiple rounds of review by different teams, often against conflicting requirements. Trusts would welcome a more streamlined governance structure, characterised by clear accountability, consistent expectations, and a single, clearly accountable stakeholder.

While trusts support the adoption of a programmatic approach to the NHP, trust leaders highlight that some of the smaller schemes or projects are being slowed by processes designed for larger hospitals, adding unnecessary complexity and delaying benefits for staff and patients. They urge that these schemes could progress faster if managed independently, with streamlined governance and lighter reporting requirements.