David Jones, director of estates, facilities & capital development, University Hospital Southampton NHS Foundation Trust & PhD research student University of Southampton investigates the impact of hospital maintenance backlog.
Backlog maintenance in the NHS has been a growing issue for years, posing serious risks to patient safety, staff efficiency, and financial performance. Two years ago, an article in HEJ titled “Badly maintained buildings can be a risk for all" highlighted the escalating problem.
At that time, backlog maintenance costs stood at £9.2 billion, with £1.6 billion classified as Critical Infrastructure Risk (CIR).
As of 2023, these numbers have risen sharply to £11.6 billion in backlog and £2.4 billion in CIR.
The increase in backlog maintenance has affected the physical state of buildings, the functionality of equipment, and overall infrastructure. Projections suggest that by 2028/29, backlog maintenance could reach £25 billion, with over one-third categorised as CIR, a situation that threatens to impact patient care, operational efficiency, and financial sustainability.
Financial impact
The financial implications of backlog maintenance extend far beyond repair costs. Every time an operating theatre or ward is closed due to infrastructure failures, trusts lose thousands of pounds in revenue and valuable staff time. In addition, hospital bed closures, caused by estate issues, exacerbate system-wide pressures, resulting in delays in patient admissions and ambulance handovers.
Cumulatively, these disruptions cost the NHS tens of millions of pounds annually.
Several factors are driving the growing financial strain. Deferred maintenance accelerates asset deterioration, turning minor repairs into costly replacements.
The faster increase in the Critical Infrastructure Risk (CIR) compared to the overall backlog – rising from 13 per cent in 2019 to 23 per cent today – illustrates this trend. While inflation has pushed up costs, if inflation were the sole factor, the backlog would have only reached £5.33 billion.
The larger increase stems from neglecting essential repairs. Over the past decade, many NHS trusts have faced shrinking estates budgets, forcing them to focus on urgent, reactive fixes instead of planned maintenance.
Impact on patient safety
The risks associated with backlog maintenance are most starkly reflected in patient safety. As healthcare facilities age, incidents linked to infrastructure failure have doubled since 2011/12, amounting to over 115,000 reported incidents in 2019/203.
These risks include both active failures, such as a patient tripping due to environmental hazards, and latent risks, such as poor ventilation contributing to hospital-acquired infections.
A 2022 report from the British Medical Association (BMA) found that 43 per cent of doctors believed poor workplace conditions were negatively affecting patient care, while 38 per cent rated their facilities as poor or very poor4.
Recent ERIC data also revealed that over 2,600 patient treatments were delayed or cancelled due to infrastructure issues.
Operational and staff implications
Backlog maintenance also impacts staff morale and retention. NHS staff already face immense pressures, and working in poorly maintained environments further diminishes job satisfaction.
Issues like faulty equipment, leaks, and inadequate heating not only frustrate staff but also affect their ability to provide high-quality care. This results in higher staff turnover, which further strains an already stretched workforce.
Beyond morale, operational disruptions caused by infrastructure failures – such as ward closures – result in cancelled procedures, contributing to longer waiting lists and delayed care. These disruptions ripple through the system, causing inefficiencies and increasing patient wait times.
Environmental and public perception
Outdated infrastructure also hampers the NHS’s ability to reduce its carbon footprint. Aging facilities tend to be less energy-efficient, and frequent short-term repairs hinder the implementation of sustainable, long-term solutions.
Moreover, the poor condition of NHS estates damages public perception, creating a narrative of neglect that can undermine confidence in the system.
This is borne from recent reports stating that the public’s confidence in the NHS is at an all-time low.
Research and academic perspectives
Studies show that good Evidence-Based Design (EBD) improves patient outcomes5 but has limited impact due to long implementation cycles in the NHS.
In other words, we are rarely able to put theory into practice as we seldom build new facilities. Therefore, maintaining what we have is crucial, and the failure of the infrastructure can have significant impacts on the system.
The author is undertaking research studies to understand the broader impact of backlog maintenance. One study is using AI and large language models like Google’s “BERT” to analyse over 4.8 million patient safety incidents to identify the role infrastructure failures play in patient harm.
Another study applies Operations Research methodologies to map out the causal relationships between infrastructure failures, patient harm, trust finances, and staff morale.
This study invites directors and senior leaders of acute trusts in estates, finance, HR and nursing to contribute to this research (details below).
Addressing the backlog: future steps
Addressing backlog maintenance requires a multifaceted approach. Research into infrastructure failures must be expanded, and decision-makers need access to better data to understand the long-term costs of deferred maintenance.
Current studies are focusing on how backlog maintenance impacts patients and staff, aiming to provide actionable insights.
In addition, investment in proactive rather than reactive maintenance is crucial. Waiting for central government to inject funds will not suffice. The NHS needs a more strategic, long-term plan that incorporates modern data analytics and A.I. application to identify and address critical infrastructure risks before they escalate further.
Conclusion
Backlog maintenance in the NHS poses a significant risk to patient safety, financial health, operational efficiency, and staff wellbeing. If left unaddressed, these issues will only worsen, leading to higher costs and declining care quality.
A comprehensive, data-driven approach to maintenance and infrastructure management is essential for ensuring the long-term sustainability of the NHS.
By investing in the infrastructure that supports healthcare delivery, the NHS can not only improve patient outcomes but also secure its future in an increasingly complex and demanding healthcare landscape.
