NHS capital expenditure and financial management Contents

2Investment for the future


16.NHSE&I acknowledged that over the last few years, trusts have had to use some of their capital budgets to sustain day-to-day services (£1.2 billion in 2016–17, £1 billion in 2017–18, £500 million in 2018–19 and £470 million in 2019–20). NHSE&I told us that its aim is that this falls to zero this year.35 As at October 2019, trusts reported an estimated total backlog maintenance cost of £6.5 billion to restore their estates to an appropriate standard, of which £1.1 billion was high-risk, indicating an increased risk of harm to patients. NHSE&I acknowledged that having well-maintained hospitals is highly desirable, and the Department noted that there is now a clearer focus on directing capital funds to local areas with the greatest need.36

17.Making better use of capital investment and its existing assets to drive transformation is one of the key financial commitments in the NHS Long Term Plan.37 The Department had intended to announce its capital strategy for 2020–21 to 2024–25 in the autumn 2019 Spending Review. However, a one-year spending round was delivered given the government’s focus on exiting the EU, with a full spending review postponed to 2020.38 In October 2019, the Department published the Health Infrastructure Plan which announced £2.7 billion for hospital projects for six NHS providers between 2020 and 2025.39 During the COVID-19 pandemic, transformation of services was halted and capital expenditure requests from trusts were required to be clearly linked to delivering the COVID-19 response to ensure the immediate needs of the pandemic were met. The Department explained that, before the COVID-19 pandemic, the government had an extensive range of capital plans, but still had several decisions to make about longer-term capital that were put on hold.40

18.We asked NHSE&I if the historic backlog of maintenance costs had a bearing on the COVID-19 response. NHSE&I told us that although they had to respond quickly and flexibly to re-purpose capacity, this had not been the main constraint in the response.41 During the COVID-19 response many NHS services have switched to being provided digitally, such as remote consultations. NHSE&I noted that this is the direction of travel set out in the NHS Long Term Plan. However, it acknowledged that new investment is required for additional capacity on a “permanent basis”, including critical care, general and acute beds in hospitals and additional capacity in community care settings.42


19.The NHS continues to have around 40,000 nursing vacancies and 9,000 vacancies for medical staff. Local NHS bodies have also reported that staffing shortages are one of the biggest risks to delivering the NHS Long Term Plan. The NHS’s own estimates indicate that demand for nurses is likely to outstrip supply for some years to come.43 We asked NHSE&I what impact these shortages had on the COVID-19 response. NHSE&I commended the response of NHS staff, not only the current workforce, but also staff returning to the workforce and nursing and medical students, who have all come together at very short notice. It told us that: around 8,900 clinical staff, nurses, therapists and midwives had been redeployed back to frontline services and another 1,800 joined the coronavirus 111 service; and 30,000 student nurses, midwives and allied health professionals came forward to be deployed into paid placements, as did 3,000 final-year medical students. However, it stressed that this is not sustainable and it is considering alternative options for training new staff.44

20.The NHS Long Term Plan acknowledged in 2019 the need to increase staff numbers. The NHS intended to publish a people plan in 2019 to set out its strategy for the future NHS workforce to meet its service commitments and to support the NHS Long Term Plan. However, publication of the people plan has been repeatedly delayed, most recently because of the COVID-19 pandemic, and only an interim, non-costed plan has been published to date.45 The Department was unable to give a definitive timeframe for when the people plan will be published.46

21.NHSE&I emphasised that the responsibilities for education and training of NHS staff, including its budget, are spread across several bodies including the Department, NHSE&I, Health Education England and universities. It explained that it has a broad understanding of the training and recruitment requirements for the NHS, and that this view is shared across Health Education England and the Department.47

Personal protective equipment (PPE)

22.There have been numerous reports in the media and from professional bodies on shortages of PPE for clinical and social care workers during the pandemic.48 The Department told us that the stock of PPE for health or social care has never run out at a national level.49 It explained that the main challenge it faced was to distribute the right PPE to the right place on a timely basis, noting that the Chief of the Defence Staff, who helped with the logistics, described it as the biggest logistical challenge he had seen in his 40 years of military service.50 The Department noted that before the coronavirus pandemic, national purchasing of these types of item was running at around 35% to 40% of the total, with other purchasing being done on either a regional or a local basis. It told us that this was sufficient outside crisis time, but was not able to cope with the surge in demand during the crisis and it therefore has had to put in place new arrangements in a very short time.51

23.The Department explained that it had moved from supplying 240 trusts to trying to supply 50,000 customers across health and social care. Before the pandemic, the Department did not have a role supplying PPE to private social care providers and it told us that coordinating with so many different organisations was an enormous challenge. It also noted that the opaque nature of the social care system made scaling up provision quickly much more challenging than in the more established NHS.52

24.The Department told us that it buys the vast majority of its PPE on international markets and that it wants move from a situation where it is meeting PPE need day-by-day to having security of supply over some months.53 Given the challenges that procurement on international markets poses in terms of price and not always being at the front of the queue during a global pandemic, we asked the Department if it plans to change the way it procures PPE. The Department told us that there are decisions to be made about the resilience of its supply chains. It noted that building up domestic production is one thing it can do to make supply chains more resilient. However, it conceded that in the current crisis, although domestic production will make a contribution, there is no imminent possibility that it will replace what it needs to buy on the international markets.54

35 Qq 38, 51

36 Qq 45–46, 53, 57; C&AG’s Report Review of capital expenditure in the NHS, para 8

37 NHS England, The NHS Long Term Plan, para 6.3, August 2019

38 Q53; C&AG’s Report Review of capital expenditure in the NHS, para 16

39 C&AG’s report Review of capital expenditure in the NHS, Figure 16

40 Qq 47, 53

41 Q55

42 Qq 29, 43–45, 50

43 Qq 59, 74; C&AG’s Report NHS financial management and sustainability, para 8

44 Q59

45 Report by the Comptroller and Auditor General, The NHS nursing workforce, Session 2019–20, HC 109, 3 March 2020, paras 2 and 11

46 Qq 60, 73 and 74

47 Q69

49 Qq 2–8

50 Qq 4, 6–7

51 Qq 2, 4, 12.

52 Qq 2, 4–8

53 Qq 4, 14

54 Qq 16–17

Published: 8 July 2020