What can we do to accelerate NHS Capital?
Originally written as 2025 New Year’s Resolutions, this is a set of suggestions for how we can make the NHS capital landscape easier to navigate - and introduce agility into NHS capital processes.
The rumble of dissatisfaction with our NHS Hospital Estate is growing. Here are the six things that I'd suggest the NHS do this year.
Want the short version?
Get Five NHP Projects to FBC: Delivering Full Business Case (FBC) approvals for at least five New Hospital Programme (NHP) projects by year-end. Why? Read more below.
Simplify the Business Case Process: Fix the NHS’s broken capital approval process by reducing duplication, clarifying roles, and streamlining approvals for smaller and strategic capital projects. How? Read more below.
Refocus Hospital 2.0 as a Resource: Shift from imposing a rigid standardised design to offering a library of best practice and innovative ideas that adapt to local needs and existing infrastructure. What and how? More below.
Rethink Hospital Scoping: Reduce the capital burden by descoping hospitals, by transitioning services to community and digital settings where feasible, and focus on efficient use of space. Pie in the sky? Maybe – but perhaps I can convince you.
Solve the Reluctance on Big Projects: Challenge defeatism surrounding large-scale hospital projects. Aka: Sometimes you have to stump up billions.
Bring back PFI: Nobody really thinks that the huge renewal and rebuilding task ahead of the NHS can be delivered through capital budget alone. End the ban on private finance and bring back PFI, in a better form.
Here's the why and how:
1. Get Five NHP Projects to FBC
Since the Health Infrastructure Plan (HIP) was launched in 2019, progress has been disappointingly slow. Only one project on that list – the Dyson Cancer Centre in Bath – has reached Full Business Case (FBC) approval and moved into construction. This £50m project, funded largely through the New Hospital Programme (NHP), is the sole tangible result of a programme intended to deliver 40 new hospitals (reference).
Delays have compounded delays. The Government’s review of the NHP, while absolutely necessary, has inevitably slowed progress further. Additionally, the pursuit of the Hospital 2.0 (H2.0) design template – a centralised, standardised hospital model – has also caused delays without yet delivering. The publication of H2.0 details, initially promised for May 2024, remains overdue.
Despite a very sensible February 2023 announcement to relax H2.0 requirements for frontrunner projects, no additional FBCs have been approved. Delays lead to cost increases, as highlighted in projects where estimated costs have substantially increased due to prolonged uncertainty.
The new Government’s review creates an opportunity, not only to create a prioritised and timetabled list of schemes which have Government support, but also to enshrine these schemes into Government policy. That should help to simplify and speed up the business case approval process: Once these projects are locked into policy, the question starts to shift from “should they be done?” to “how do we deliver them?” Let’s start by getting five projects to FBC and show progress.
2. Simplify the Business Case Process
Burrum River Advisory Business Case Process Summary
The NHS capital approval process is convoluted and slow. Achieving funding approval requires navigating 3-5 business cases, sequentially approved by up to seven different bodies. Each layer of scrutiny brings new refinements and demands, often leaving projects stuck in iterative cycles. Approval bodies understandably see their job as being to correct and improve the details of each case – and the more approval bodies there are, the more the cycle extends as cases are sent back to lower levels.
When NHS business cases eventually reach the Department of Health and Social Care (DHSC) and HM Treasury (HMT), they are often unfamiliar to, and certainly not owned by, those reviewing them. Unlike other government departments, where DHSC and HMT typically work collaboratively on cases from an early stage, the NHS’s process isolates these key stakeholders until late in the approval cycle.
This lack of early involvement creates a cascade of inefficiencies:
Redundant Questioning: Because cases are new to DHSC and HMT, they prompt another layer of scrutiny, delays, and revisions.
Outdated Information: By the time cases reach higher levels, they may be slipping out of date, reflecting initial assumptions that continue to shift.
Increased Costs: The complexity and length of the process significantly inflates adviser fees, NHS resource commitments, and overall project costs.
Reduced Agility: Long approval timelines undermine the NHS’s ability to respond quickly to government priorities or emerging needs.
Adding to the burden is the way we complete business cases: SOCs that run into hundreds, if not thousands of pages; the NHS England Strategic Outline Case (SOC) checklist (while helpful) comprises roughly 150 items. Each subsequent stage—Outline Business Case (OBC) and Full Business Case (FBC)—builds on this foundation, exacerbating the scale of work.
Further complicating matters, the roles of new entities like the National Infrastructure and Service Transformation Authority (NISTA) and the Office for Value for Money (OVfM) remain unclear. If not managed carefully, these bodies could add even more hurdles to an already bloated process.
Suggested Path Forward
We are unlikely to see the elimination of DHSC or HMT oversight, nor a reduction in the required SOC, OBC, and FBC stages. However, several pragmatic reforms could make the system faster, more efficient, and better aligned with government priorities:
A. Distinguish Between Tactical and Strategic Capital
Define capital projects over (say) £75m as strategic, requiring national oversight. For projects below this threshold:
Provide Integrated Care Boards (ICBs) with tactical capital budgets that have de facto DHSC and Treasury approval through the budget allocation process.
Allow ICBs and Trusts to allocate these funds locally, simplifying approvals for smaller-scale projects and fostering responsiveness to local needs.
B. Create a DHSC Strategic Capital Team
Move the national Estates Team and the New Hospital Programme (NHP) into DHSC to form a single strategic capital team. This team would:
Serve as an in-house adviser and “intelligent client” for Trusts. There needs to be a culture of service to Trusts in this team. Top-down direction slows down and frustrates NHS projects.
Act as a bridge between Trusts and DHSC, facilitating closer collaboration and aligning projects with departmental priorities.
Address the current gap between the NHS and other government departments, where approvals often feel like external reviews rather than the culmination of a collaborative process.
Other departments, for example, effectively approve their own cases – cases that they have already more or less co-authored with HMT and NISTA. The NHS needs to adopt a similar approach, ensuring that its business cases are “owned” by the bodies tasked with approving them.
C. Transform NHSE and Other NHS Bodies into Consultative Roles
Change NHS England (NHSE) and related entities from approval bodies to consultative ones:
Trusts should consult these bodies, document their feedback, and demonstrate alignment with national policies.
When submitting cases to DHSC, Trusts should copy in NHSE and other bodies, enabling them to raise objections if they believe their feedback has been mishandled.
This would eliminate the iterative round-robin process of approvals within the NHS before cases are even seen by DHSC and HMT and give the NHS back some of the agility enjoyed by other parts of Government. It would however also ensure that local and national voices are still heard.
D. Integrate PCBCs and DMBCs into Existing Business Cases
Pre-Consultation Business Cases (PCBCs) and Decision-Making Business Cases (DMBCs) increase the number of required business cases by 40%. These stages often duplicate the work already embedded in the SOC, OBC, and FBC processes. Consolidating PCBCs and DMBCs into the broader business case structure could reduce complexity and accelerate progress.
3. Refocus Hospital 2.0 as a Resource
We already have comprehensive standards for hospitals in the form of Government’s Health Building Notes. It’s hard to see that H2.0 isn’t reinventing these and might even clash with them. Equally, given the huge effort and expense put towards H2.0, it’s hard to imagine that there isn’t some good stuff in there that might well reduce costs or improve quality.
We need to be realistic though: most of the New Hospital Programme are parts of hospitals and H2.0 will only partly apply to them anyway. For these schemes, there will need to be derogations from the ideal to cater for local requirements and existing infrastructure.
The NHP was always facing an uphill battle to impose a centralised design requirement onto local Trusts. Instead, let’s use the IP gathered from this exercise to support local teams to improve their designs and make their projects more affordable. The DHSC Strategic Capital team suggested above would be natural champions for these ideas and could help teams to navigate between the HBNs and H2.0 ideas. This would allow local teams to get on with their projects without waiting further for H2.0 and it would also mean that H2.0 becomes an evolving set of ideas which not only supplies Trusts with ideas but also collates good ideas from local projects and socialises these more broadly. Any of us involved in the PFI programme will remember that one of the weaknesses of that programme was that good ideas from one PFI project were often not replicated by others. This would help solve that communication problem.
4. Rethink Hospital Scoping
Capital costs have risen significantly over the past decade, requiring a hard look at how NHS facilities are used. Hospitals often include services that could be delivered more effectively – and cheaply – in community settings or online. I hesitated to add this one because I can already hear people shouting “Not this again!” But the fact is that I do believe there is more to gain here. The fact is that capital works have become disproportionately expensive in the last 10-15 years, for a range of reasons. So we need to be much more sober about how we spend it. So we need to ask questions like:
Do we need vast outpatient spaces when hardly any of us meet in person anymore? Of course, there are examples of outpatient appointments which must be face to face, but there’s no way that it needs to be anything like the scale that most hospitals routinely provide for.
How many jobs in the NHS can be done from home – at least a few days per week? This combined with hot-desking (including for senior consultants!) could significantly reduce office space requirements.
How much elective bed space do we need when most procedures are now ambulatory?
How many services (therapies, diagnostics, administration, residual outpatients) actually need to be delivered in hospital buildings? Community facilities and office blocks are much cheaper, and by locating them in town centres, the NHS can play a better role in regeneration, deliver better access and save money.
How can we enhance and expand the role of GPs? Not long ago we were worried about a cliff edge created by an ageing GP population. Now there seems to be a problem with unemployed GPs. What are we doing here?
Can we develop new spaces for step-down care? We all know that there are lots of medically fit people in expensive hospital beds. DHSC includes social care. I know the rules and budgets get in the way but really? Surely, we can cut through this to get people into better and cheaper settings than hospitals and use this to descope hospitals and reduce the capital costs overall.
I’d be really interested in comments about whether it really is cheaper, from a capital perspective, to deliver services in the community. Informal conversations that I am having suggest that spaces in the community can be 30-50% cheaper to build than spaces in hospitals. What’s driving that? Why can’t that be replicated in a hospital setting? Regardless of the answer though, it seems to be that the NHS, as the largest employer in most communities, has a responsibility to play a role in urban renewal and regeneration.
5. Solve the Reluctance on Big Projects
Assuming that we’ve done all we can to address the cost opportunities in 4 above, we will still have projects like St Mary’s, Addenbrookes 3 and University Hospital Wales 2 which require really big amounts of money. There’s a certain defeatism at some levels of the health service that it’s just too big and insoluble because of the amounts involved. That just has to be challenged. We live in a country where we are delivering HS2 for £45bn, Hinkley Point C for £22bn, Crossrail for £19bn, the Lower Thames Crossing for £7bn, new Jubilee and Piccadilly Line rolling stock for a combined £8.5bn. We need to be prepared, now and then, to spend significant sums on updating our major hospitals, particularly where these are major research hubs, at the centre of economic activity around innovation and life sciences. For better or worse, our health system is a huge part of our economy and the UK has a real opportunity to build on GDP-generating life sciences centres like Cambridge and London and accelerate efforts in places like Oxford, Edinburgh, Glasgow, Liverpool, Manchester and Cardiff. But you can’t do that with crumbling NHS infrastructure. Investors are just not attracted to that when they can work with modern centres elsewhere.
Let’s be more open to the case for bold investments in flagship hospitals. These facilities are not just healthcare providers but vital parts of the UK’s economic and research ecosystem. Modernising them isn’t optional; it’s essential to maintaining the NHS’s global reputation and competitiveness.
6. Bring back PFI
Controversial of course. But the NHS capital budget is not, on its own, going to be sufficient to reverse years of underinvestment, bring assets up to scratch, fund ongoing equipment replacement programmes and modernise NHS IM&T all at once. Even with the kind of increases I’ve argued for before. There is a way to do PFI better this time around - and, if we get it right, we don’t need to use the capital budget for it, though there will of course be a longer term revenue hit. Here is my prescription for a better PFI.
Closing Thoughts
These resolutions focus on practical steps to address the inefficiencies and delays that have plagued NHS capital projects. With decisive action, the NHS can improve its infrastructure while reducing costs and delays. It’s time to move forward, not in small steps, but with the confidence and urgency that the sector – and the country – deserves.
