Why the NHS can no longer afford to ignore the cracks in the ceiling
Lack of investment in buildings and equipment has left nurses working in poor conditions
Lack of investment in buildings, new equipment and maintenance has left nurses working in poor conditions and struggling to deliver care
- Money that should be earmarked for repairs and replacing outdated equipment is being used for the day-to-day running of the NHS
- The NHS has been forced to sell off 'surplus' land but the money made is not being used for capital investment, nor is the promise of affordable housing for staff being fulfilled
- The continued underinvestment has had a negative effect on morale and retention of NHS staff
Care Quality Commission (CQC) inspectors are prepared for most things – but probably not the building collapsing around them.
But in 2015, inspectors at Bootham Park Hospital in York saw cracks in the ceiling of the 250-year-old building. Part of it collapsed shortly afterwards, and the CQC decided the mental health hospital should be closed citing ‘significant risks’ to patients from the poorly maintained building. In an ideal world it would have been replaced or repaired.
But the NHS is not ideal. It is short of the capital needed to replace or refurbish old buildings or to invest in new diagnostic and IT equipment. This situation has led to a backlog of building work and has also hampered the development of better services and made life more challenging for staff who may struggle to provide care in substandard buildings.
Lack of spending
Research from the Health Foundation says the UK spent just 0.27% of its gross domestic product on healthcare capital in 2016 – about half the rate of comparable countries. Apart from 2007-09, spending has been below the average rate of other countries since 2000. There is also a backlog of maintenance work of more than £6 billion.
In many cases this will have an effect on nurses. Jennie Down left her job as a practice nurse on the Isle of Wight after four months because she was fed up of working with poorly maintained equipment. The couch used for cervical smears did not work, the light constantly flickered and the IT system would not work properly, causing delays to care.
‘It probably would have been about £200 to repair all of these things,’ she says. ‘The practice had a blackboard where we could report these things but they never got fixed. I felt I could not do the job any more. I’m 55 and I had intended to work for a few more years, but I handed in my notice and when the time came to revalidate I just didn't bother.’
Other nurses have told Nursing Standard of problems finding working bladder scanners and ECG machines. RCN London regional director Jude Diggins says offices for nurses working in the community can be in a particularly poor state because they are not seen by patients. Lack of IT spending also creates challenges. ‘We talk about electronic patient records but it can be difficult to get a signal when you are visiting people in their homes. Community nurses have to go somewhere to write up their notes – and it is often done in their own time.’
‘They have sold the family jewels and have balanced the books for one year, but we are not addressing the underlying deficit’
Jude Diggins, RCN London regional director
And nurses working in hospitals can face sweltering temperatures during the summer as there has been little investment in air conditioning, she adds.
Freedom of information requests by the Labour Party have revealed estates and infrastructure problems in 2018-19 including nurses being trapped in broken lifts, part of an emergency department being closed due to a sewage leak, problems with heating systems and crumbling ceilings.
Decline in morale
It is not just nurses who are concerned about this: their employers are as well. Senior managers questioned for a research project run by the Health Service Management Centre at the University of Birmingham suggested that low morale and a failure to recruit staff were linked to the poor built environment caused by constraints on capital spending. This has led to a greater dependence on agency staff.
Being unable to invest in new premises in the community has meant services have been kept in acute hospitals instead of being set up closer to people’s homes. And shortages of equipment – and the tendency to not replace older equipment prone to breakdowns – means staff time is not being used effectively.
What the lack of capital has meant to one trust
East Kent Hospitals University Foundation Trust is one of the trusts with the highest backlogs for work on its estates – which include three major hospitals as well as community services. The trust is expecting a major reconfiguration of services over the next few years but while this is decided, staff continue to work in buildings that need more than £70 million in repairs and improvement work – £28 million of which are judged to be urgent.
In 2017-18 the trust had 214 reported incidents that put patients at ‘harm or risk of harm’. Some were related to high temperatures – which led surgeons to threaten to cancel operating lists – while others included leaking ceilings and broken lifts. Many of these affected staff at the hospitals, with one nurse commenting: ‘We dread the summer months. We shouldn’t have to work in an environment that means we are pouring with sweat and feeling sick. We shouldn’t have to bring in a spare uniform as we are drenched through by 10am on a 12-hour shift.’
Overcrowding and lack of privacy
One nurse from the RCN’s East Kent branch said that the size of the hospitals had not kept up with population growth – leading to overcrowding and difficult working conditions in the emergency department. Noisy conditions and lack of privacy for patients are common, and in some areas it is difficult to reach the sink to wash hands if other people are in the room. Lack of investment has left nurses scrambling around for equipment.
The trust said some of its estate dated back to the 1930s but it worked hard to keep it up to date and had applied for £34 million in emergency capital for replacement plant and equipment.
‘Since last summer we have invested £6 million in various projects to improve the sites, the main focus of which was temperature control, including installing more than 90 additional air conditioning units, as well as improving main entrances and over 29 staff areas across the trust. The units now have the option of cooling in the summer months and heating in winter,’ it said.
‘As part of our ongoing maintenance programme we invest over £2 million per annum in maintaining a very large and complex estate. In the past ten years the trust has invested £220 million in the environment, technology and equipment.
‘Equipment is maintained to the best of our ability and any faults are dealt with in specified timescales.’
Workforce policy adviser at NHS Providers, Finn O’Dwyer-Cunliffe said: ‘Underinvestment in the NHS estate affects the quality of services for patients as well as the experience of staff and the care they can deliver.
‘Faulty or outdated equipment increases the workload for staff, leaving them spending more time on admin and having less time than they would like with patients. The poor condition of some areas means that staffrooms are having to be closed.
Abandoned transformation plans
‘This affects the ability of doctors and nurses to take breaks and ensure they are sufficiently rested, and can harm the morale of an already overstretched workforce.
‘Capital investment in the NHS leads to greater productivity. For example, community nursing is one area that could see significant benefits for staff and patients of a shift to more mobile and flexible working. Investing in technology including ICT, electronic records and e-rostering helps ensure the right staff are best placed to look after patients and service users, while transforming and modernising NHS facilities means they are properly equipped to provide care.
‘Trust leaders want to improve working conditions for their staff. However, trusts urgently need access to capital funding to enable this investment.’
Joshua Kraindler, one of the authors of the Health Foundation report on capital spending, Failing to Capitalise, points out that it is not just the overall levels of spend that has an effect – it is the uncertainty.
‘Trusts can’t necessarily spend money even if they have a surplus,’ says Mr Kraindler. This drives short termism, where trusts abandon transformation plans because they can’t be sure they will get the money at the right time.
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Failing to Capitalise showed that capital spending had declined as a share of overall NHS spending and in real terms from 2010-11 to 2017-18. This was mainly due to capital budgets being raided to prop up the day-to-day running of the service. Where the NHS had sold off assets, such as spare land, this had often not been reinvested in capital projects but had instead been spent on running costs.
Sadly, it does not look as if the NHS capital shortage is going to be solved any time soon. The increase in NHS spending announced last year did not include any decisions on capital; that was left to the spending review which was expected later this year.
The timing of that and how generous it will be is now in doubt, as the UK will have a new prime minister, and probably a new secretary of state for health and social care, and will potentially have left the European Union without a deal. It’s likely that nurses will be working in poorly maintained and poorly equipped hospitals for some time to come.
Short termism and the selling of NHS land
NHS organisations have come under pressure to sell surplus land and use the proceeds to fund capital spending. But it is unclear if this will benefit nurses.
The 2017 Naylor review of NHS land, which calculated the NHS could raise billions of pounds from land sales, suggested that NHS staff should be prioritised when land was sold for housing, with affordable housing designed to attract and retain staff especially in areas where house prices are high.
That has not happened. The New Economics Foundation says two thirds of the houses built or planned for large chunks of land recently declared surplus to NHS needs will be unaffordable to nurses on an average salary. Of the sold-off sites, 30% have no plans for affordable housing and on average the houses are 9.6 times a nurse’s salary. In some cases, it would take a nurse close to a century to save for a deposit on these houses.
Nurses face eviction
In other areas, nurses and other healthcare staff are being evicted from their homes on hospital-owned land so that the sites can be redeveloped.
Ms Diggins says in London some sites have been sold to the highest bidder and used for luxury housing, even though housing costs are known to be a significant factor in nurse retention in the capital. ‘It is a missed opportunity for trusts to think about what they can do,’ she says. ‘They have sold the family jewels and have balanced the books for one year, but we are not addressing the underlying deficit.’
Alison Moore is a health journalist