This article is part of the Inside the NHS newsletter.

Buildings might not be the first thing most people think of when they consider the priorities for a safe and efficient health service. Adequate staffing and availability of medicines or machines tend, understandably, to take top billing.

But crumbling infrastructure, backlogs of repairs, and facilities delayed by design flaws are having a real – and growing – impact on services.


Back in February of 2021 Audit Scotland warned that the NHS in Scotland was grappling with a capital maintenance backlog worth approximately £1.03 million. At that point, 71% of the estate was considered "suitable for purpose" and 7% of necessary repairs were "high-risk" – meaning they jeopardised clinical services.

In its update in February of this year, the public spending watchdog cautioned that the value of this backlog was "likely to have increased". The Scottish Government has pledged to double its investment over the next five years to address these issues, but it faces challenging headwinds.

As health secretary, Michael Matheson, noted this week in evidence to Holyrood's health and sport committee, governments are getting a lot less bang for their buck.

Construction inflation "is running away ahead of standard inflation", in double digits, which means that the money they have buys less than it used to, while the capital budget Holyrood receives from Westminster has also been cut by 5%.

In recent weeks the committee has been told by the chief executive of NHS Greater Glasgow and Clyde that the Inverclyde Royal and Royal Alexandra hospitals each have maintenance backlogs worth £100m and £80m respectively.

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The most scandalous example, however, is the institute of neurological sciences – based at the Queen Elizabeth University Hospital (QEUH) campus in Glasgow – where MSPs were told there had been "17 instances of patient death or harm in the last five years" as a result of issues with the facility.

The health board has spent some £3 million sending patients for brain and spinal treatment at private hospitals instead.

Meanwhile, the A&E department at the Royal Infirmary of Edinburgh – built 20 years ago to handle 85,000 people a year – is now dealing with 120-130,000 amid a "significant population drift" from the west of Scotland to the east. Little wonder it is under strain.

NHS recovery?

Audit Scotland, in its report in February of this year, warned that the Scottish Government faces tough decisions. It would "have to balance capital investment with the other financial pressures it faces".

This "could affect progress in recovering services and increasing capacity, and therefore have a negative impact on patients".

Far from ideal at a time when the NHS is playing catch up with its more headline-grabbing backlog: the 17,000 people who have been waiting over 18 months or two years for an operation.

On the ground, frontline medics describe frustration.

One consultant in orthopaedics told me they feel torn between being "told to do more and then, in the next breath, we're told 'there's not more resource'".

They added: "There's operating theatres that aren't working because they're broken or they need to be refurbished, and we don't have money for that. Then we need people to staff the theatres, but we don't have money for that.

"We're cutting back on evening and weekend staffing to save money by putting fewer people through scanners, but that just means we've got inordinately long waits for things like MRIs.

"You end up with this great list of things that need to be done in order to make a difference, and none of them are being done."

New builds?

Shiny new facilities might seem like a more cost-effective solution than patching up old buildings, but recent history tells us they can throw up their own problems.

Glasgow's "superhospital" – the QEUH and its adjacent Royal Hospital for Children – opened "on time and on budget" to much fanfare in 2015, but the wheels soon came off amid suspicion from clinicians that child cancer patients were being struck down with puzzling frequency by an unusual range of bugs seemingly originating in its water systems.

Meanwhile, the opening of the delayed and over-budget new children's hospital in Edinburgh – with a price tag in excess of £430m – was thrown into chaos in 2019 when a last-minute inspection identified flaws in its ventilation which risked exposing critically ill patients to airborne pathogens.

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Both projects are now the subject of the ongoing Scottish Hospitals Inquiry.

Meanwhile, in an alarming case of déjà vu, the new Baird Family Hospital and Anchor cancer centre in Aberdeen – both originally scheduled to open in 2020 – have been delayed respectively until September 2024 and October this year after problems with their ventilation and water systems were identified by NHS Assure, the newly-created quality control body which rubber stamps all new NHS buildings.

The overall cost has gone from £163m to £261m.

But taxpayers and patients should be reassured, Mr Matheson told MSPs, because this means the system is working: "If anything it's a demonstration of the lessons that have been learned from previous experiences where facilities were about to open and then problems were identified – they've been identified at an earlier stage."

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