NHS capital no longer has a process problem. It has a delivery culture problem
The NHS has previously delivered major capital programmes at pace. The difference was not simpler projects or weaker governance. It was political and administrative leadership that created a culture that prioritised delivery over optimisation.
In my previous article, We fixed much of the NHS capital process. So why is investment still so hard?, I argued that the explanation for slow NHS capital delivery can no longer simply be “too much bureaucracy”.
That is still part of the story. There remain too many consultation layers, too many opportunities to reopen settled assumptions, and too much duplication across organisations. Further simplification would help.
But those issues no longer adequately explain the scale of the problem.
Over the last few years, the NHS capital system has become materially less restrictive than it once was. Delegated approval limits have increased. Simplified business case routes now exist for smaller schemes. Providers have more direct routes to DHSC engagement. Treasury has moved towards longer-term capital indications and multi-year planning assumptions.
Yet major projects and programmes still move painfully slowly.
The uncomfortable conclusion is that the NHS capital system now suffers less from excessive formal process than from a deeply embedded delivery culture problem.
The NHS has delivered major capital programmes before
The NHS has previously demonstrated that it can deliver major investment programmes at pace. Following the establishment of the PFU in 1994 and the 1997 NHS (Private Finance) Act, the PFI programme moved rapidly into delivery. By 2002, 11 major NHS PFI hospital schemes had already opened and 13 more were under construction.
The Independent Sector Treatment Centre programme moved even more quickly. Launched at the end of 2002, Wave 1 facilities were already operational within a few years and, by 2006, 48 ISTCs were open or under development, with the programme already moving into operational management and preparation for re-procurement.
The contrast with the New Hospital Programme is difficult to ignore. The NHP was launched in 2018. Yet by 2025 even the Secretary of State was acknowledging that “not a single new hospital was built in the past 5 years” beyond schemes already inherited in advanced stages of development. The programme has become highly sophisticated institutionally while still producing very little new physical infrastructure.
It cannot simply be that hospital construction is uniquely difficult today. PFI schemes involved enormous technical, financial, and commercial complexity. ISTCs were politically controversial, operationally sensitive, and centrally controlled. Neither programme operated in an easy environment.
The difference was not centralisation
The ISTC programme was highly centralised. Political control was strong. National leadership was direct and interventionist. Yet the programme still moved quickly. Central teams were expected to unblock delivery, not merely supervise it. Assurance and facilitation were seen as complementary rather than contradictory.
Earlier programmes operated within a delivery culture
The real difference was cultural:
Earlier programmes operated within a delivery culture.
The current system operates within an assurance culture.
Under PFI and ISTCs, the expectation was that programmes would move at pace. Political and administrative leadership focused relentlessly on operational delivery. Timetables mattered. Momentum mattered. Delay carried consequences.
We didn’t assume contracts would be perfect.
We didn’t believe that every technical issue could be resolved in advance.
We didn’t believe that risk could be eliminated entirely.
The objective was to deliver assets and services that generated economic, operational, and political benefit, not perfect programmes and projects. Problems would inevitably arise during delivery, but that was accepted as the price of progress.
Today’s system operates within an assurance culture
Today’s system often behaves as though imperfect delivery is more dangerous than non-delivery.
That changes behaviour throughout the system.
National teams place huge emphasis on standardisation, technical optimisation, commercial refinement, and assurance. Local organisations respond by trying to produce ever more defensible and “bulletproof” cases before exposing schemes to scrutiny.
The result is an endless cycle of refinement.
Cases become larger.
Consultancy costs increase.
Timelines stretch.
Assumptions are repeatedly revisited.
Programmes and projects become trapped in prolonged pre-delivery phases.
Nobody gets criticised for strengthening a business case.
Nobody gets sacked for adding another gateway review.
Nobody faces serious institutional consequences for delay itself.
That incentive structure matters.
Post-Grenfell, post-Carillion, and following the extraordinary fiscal and operational shock of Covid, some of this caution is understandable. Governments today operate in a harsher audit, procurement, and public accountability environment than the one that existed during the early PFI era.
But we should not overstate the difference. Earlier generations of NHS capital delivery were hardly risk-free. The system delivered through the collapse of Jarvis, and John Laing, and Metronet.
The difference was not the absence of risk.
Earlier programmes operated in an environment where senior leaders understood that failure to deliver was itself a major failure. That mindset created urgency throughout the system.
The New Hospital Programme illustrates the problem
The New Hospital Programme illustrates this particularly clearly.
The programme has invested enormous effort in central commercial models, standardisation strategies, template designs, technical consistency, and assurance structures. Many of these things are individually sensible. Some may well improve long-term value.
But the cumulative effect has been to slow delivery dramatically.
At times, the programme can appear more focused on designing the perfect future hospital model than building actual hospitals.
The irony is that many of the arguments used to justify this approach are themselves rooted in mistrust.
The centre worries that local organisations will produce inconsistent, expensive, or poor-quality schemes.
The frontline worries that transparency will trigger delay, intervention, or rejection.
So the centre strengthens control.
The frontline becomes defensive.
And both sides reinforce the behaviours they dislike in one another.
This is not fundamentally a procedural problem anymore. It is a problem of institutional psychology and incentives.
The NHS still treats every scheme as an exceptional event
The NHS capital system increasingly behaves as though every project is an exceptional event requiring bespoke scrutiny and near-perfect assurance before commitment.
That is not how most infrastructure systems operate.
Large infrastructure portfolios normally assume that:
some projects will underperform,
some will overspend,
some assumptions will prove wrong,
and some redesign during delivery will be unavoidable.
Success is judged at portfolio level. The objective is overall delivery.
The NHS still tends to judge projects individually and retrospectively. That encourages a defensive culture focused on avoiding criticism rather than achieving programme momentum.
The NHS does not just need capital. It needs development capacity
This becomes even more problematic because NHS capital delivery timelines fundamentally exceed political and financial cycles.
Even with four-year spending settlements, a major new hospital programme or project often requires:
several years of development,
several years of procurement and approvals,
and several more years of construction.
The system therefore spends much of its time trying to create certainty about events that are inherently uncertain.
That creates another major problem: development capacity (and funding).
Historically, many organisations retained enough operational flexibility to support early-stage project development internally. Years of financial pressure and productivity requirements have largely removed that flexibility.
Many organisations now struggle to fund:
strategic planning,
site development,
technical design,
business case preparation,
commercial advisory work,
and enabling infrastructure.
As a result, schemes often fail long before construction funding becomes relevant. The NHS increasingly lacks not just capital funding, but the funded institutional capacity to create investable projects.
This is one reason why simply arguing for larger capital budgets is not enough.
The more realistic solution may be development funding.
The NHS should consider:
dedicated national, regional or local development funds,
rolling project preparation facilities,
development capital linked to pipeline maturity,
and support mechanisms that help providers create deliverable schemes capable of moving within realistic spending windows.
The tone from the top matters
National leadership needs to change the tone of the system. Changing culture is one of the hardest things any leader can seek to do. But it can happen when it starts with an undiluted consistent message from the top. ISTCs and PFI benefited from political and administrative leadership, from Number 10 to Treasury to DH, which was united in the urgency to renew NHS infrastructure and deliver contestability. And that urgency from Whitehall reverberated down to the bedpans in Tredegar. There is still runway in this Parliament to deliver that sort of change.
The centre will always require assurance. Treasury will always require fiscal restraint. Public money should absolutely be scrutinised. But Government can still drive delivery. That requires national bodies to see their role not simply as assuring projects, but helping to deliver them.
Government’s message should be that there is a profound difference between managing risk and trying to eliminate it entirely.
The NHS does not lack strategies.
It does not lack standards.
It does not lack approval mechanisms.
What it increasingly lacks is a culture that drives pace and operational delivery as strongly as it rewards challenge and assurance.
Until that culture changes, NHS capital investment will remain painfully slow regardless of how many procedural hurdles are removed
