10 Year Health Plan Promises on Capital: A Turning Point?

The Government’s new 10-Year Health Plan says a lot of the right things on capital – and in doing so, it does more than many would have expected. There’s a welcome recognition that capital isn’t just about buildings, but about unlocking service change. And it makes a credible attempt to address some of the frustrations that have long dogged the NHS capital regime: slow approvals, short-termism, limited alternatives to public funding, and a disconnect between planning and delivery. Is it enough? Well, I would have gone further. But it’s the best progress we’ve seen in many years on the crunchy issues which have, for so long, ensured the NHS capital system stays broken.

Some of this does feel like it has been informed by frontline feedback. The Plan promises no more than three approval layers – even for major schemes. That might sound like a marginal gain on paper, but if it’s implemented as described – with DHSC and HMT both engaged early and constructively – it could easily save years, not the couple of months described in the Plan. And if Foundation Trusts can now progress self-financed projects without running the gauntlet of central sign-off, that could unlock a swathe of useful estate investment.

It also gives long-needed clarity on the use of land receipts. The idea that Trusts can now access funding ahead of those receipts landing – rather than waiting until after sales complete – is quietly significant, especially for site-constrained providers. It’s a long-overdue signal that trusts should be able to build upwards and sell around, without getting into expensive and potentially risky forward sales agreements. That sort of flexibility could make land values genuinely useful again.

Just as important is the shift toward longer-term capital planning. Multi-year settlements won’t fix everything – but they give providers the breathing space to think beyond year-end fire drills and make properly strategic choices. When nearly half of NHS capital has been spent in the last two months of the year, any change that encourages forward planning is worth grabbing. That does, however, put a responsibility on provider Trusts to do the job of genuinely strategic long-term capital planning, parcelled up into capital packages that they can fund (or get funded) and pre-procured; so that we don’t get stuck in a sequential process of delayed approvals, delayed procurement, budget surprises, more approvals delays, and eventual construction (no doubt, delayed).

The Plan also brings a positive nudge on self-funding opportunities like car parking, key worker accommodation and other revenue-supporting assets. Many Trusts have already been doing this – but probably not enough. Clearer backing for this type of investment is helpful, not least because these schemes are usually deliverable without CDEL and with relatively little central involvement.

Where the Plan is weakest is where the problem is greatest: the acute hospital estate. There is no real answer to the question of how we deal with the worst, most unworkable buildings in the system. And despite encouraging language on “renewed freedoms,” there’s still no allowance for acute PPP. Instead, the Plan doubles down on the community and primary estate as the place where PPP might live again.

That’s something – and in fairness, using private finance for neighbourhood health centres is sensible and long overdue. But it leaves a huge gap. We can’t keep dodging the issue that acute hospital capital is both unaffordable and undeliverable within current budgets. And with the New Hospital Programme limited in scope and still not building anything new (of significance), Trusts who’ve been waiting for a rescue now need a Plan B. The Health Plan doesn’t explicitly offer one but maybe they can create one for themselves...

There’s more alignment now between the policy signals and what many in the system have been asking for. The idea that capital investment should support a shift from bricks to clicks, from large hospitals to neighbourhood delivery, and from reactive to preventative care – that’s something the capital community can work with. And we need to be at forefront of ambitious new designs that descope services from expensive hospital settings into more affordable community buildings. The challenge will be translating that into procurement routes, delivery models, and the tech needed to deliver dispersed care.

The role of DHSC and HMT also needs to shift. Less about approval, more about enabling. Capital plans should still be Trust-led but we need earlier and greater engagement by the two approving bodies with providers. They can play a role in creating standardised contracting (especially for PPP), and they should share responsibility for case-making – as happens for other areas of Government. Trusts shouldn’t be passive applicants in a centralised programme. They need to lead, with support – not just oversight – from the centre. If that collaboration happens, there’s real potential for pace which could be opened up.

So, while there’s still a long way to go, this Health Plan at least opens many of the right doors. It gives capital a more explicit role in system reform, acknowledges the need for flexibility, and hints at a more grown-up relationship between Trusts and the centre. We should welcome that.

But we should also be clear-eyed: no matter how much the Plan says, hospitals don’t get built by documents. And until there’s a realistic path to finance large-scale acute investment – whether through public budgets or partnerships – we’ll be left trying to reconfigure care models around buildings that are long past their use-by date.

If the system now grabs this and delivers – faster approvals, real flexibility, earlier planning, and support for Trust-led business cases – then maybe, just maybe, capital might finally stop being the NHS’s least strategic resource.

More detail to follow but here’s my assessment of what was delivered against what I’ve long argued is needed: