We fixed much of the NHS capital process. So why is investment still so hard?
Many of the NHS capital system’s historic bureaucratic problems have actually been addressed. Yet major investment still moves painfully slowly.
That suggests the real problem is no longer principally procedural.
The old criticisms were not wrong
A familiar conversation keeps happening in NHS capital circles.
People talk about endless approvals, labyrinthine business cases, and the impossibility of getting investment schemes through the system. The mood is usually one of frustration and resignation. The NHS, we are told, simply makes capital investment too difficult.
The strange thing is that many of those criticisms are no longer fully true.
Over the last few years, a number of the problems previously identified by NHS leaders, advisers, and commentators have at least partly been addressed. In earlier articles including What can we do to accelerate NHS capital? and The Centre’s Role, I argued that NHS capital approvals had become excessively centralised, duplicative, and slow-moving.
Those criticisms were also widely shared by others across the service at the time. More importantly, many were valid. But several of those problems have since, at least partly, been acted upon.
Providers now have clearer routes to direct engagement with DHSC on major schemes. Delegated approval limits have increased substantially. Short-form business cases have become more common for smaller projects. Treasury has moved towards longer-term capital indications, while the NHS now operates within more stable multi-year planning assumptions than it did previously.
None of this means the system is perfect. There are still too many stages of assurance, too much duplication between organisations, and too many opportunities for previously agreed assumptions to be reopened. But it would be unfair to pretend that nothing has changed.
And yet the central complaint remains exactly the same: capital investment in the NHS still feels extraordinarily difficult.
That matters because the NHS estate problem has not gone away. If anything, it has become harder to ignore. My old Grant Thornton article Agonising about investment is holding back the NHS described an estate characterised by ageing infrastructure, major backlog maintenance liabilities, and enormous unmet demand for modernisation. Much of that analysis remains correct today.
So if at least some of the procedural barriers have been reduced, why does the system still struggle so badly to convert need into delivery?
Some bureaucracy still matters
Part of the answer is that some bureaucratic obstacles do still matter.
Despite simplification efforts, NHS capital approvals remain heavily assurance-driven. Projects still pass through multiple (but fewer) organisational layers. Technical, commercial, financial, and strategic assumptions are repeatedly tested and revisited. Business cases still evolve through iterative challenge rather than clear decision points. In many cases, the process still encourages caution more than progress.
There are obvious improvements that could still be made.
Previously agreed assumptions should not routinely be reopened without clear justification. Decision-making timetables should be tighter and more transparent. Smaller schemes should move through genuinely streamlined routes, rather than abbreviated versions of the same process.
These are worthwhile reforms. But they are no longer the whole story.
The more important problem now is cultural rather than procedural.
The NHS capital system increasingly behaves as though the greatest risk is approving the wrong project, rather than failing to deliver projects at all.
The real problem is institutional mistrust
There is a deep institutional mistrust running through NHS capital delivery.
At the centre of the system there remains a strong instinct towards control. Major national programmes increasingly describe themselves as “sponsors”, standard setters, and assurance bodies. The assumption, often implicit but sometimes explicit, is that local organisations cannot be relied upon to develop robust schemes without close oversight.
That instinct becomes even stronger when Treasury is involved. Central government naturally worries about cost escalation, political embarrassment, and accusations of poor control. One consequence is that national programmes can become heavily staffed by people whose primary expertise is governance, assurance, commercial management, or programme control rather than operational healthcare delivery.
At the frontline, meanwhile, the instinct is almost the opposite.
Providers often assume that early transparency will attract delay, challenge, or intervention. Projects therefore stay hidden. Schemes are worked up defensively. Organisations try to produce “perfect” cases before exposing them to scrutiny. By the time proposals finally emerge upwards through the system, they can arrive as surprises to national bodies that have had little meaningful involvement in shaping them.
The result is friction everywhere.
National teams push standardised approaches that do not always reflect local operational realities. Local organisations resist central direction because they expect it to obstruct delivery. Assurance becomes adversarial rather than progressive. Projects slow down long before construction begins.
Importantly, this is not primarily about individuals behaving badly. These are rational responses to the incentives created by the system.
The centre fears approving weak schemes. The frontline fears being blocked. So everybody behaves defensively.
These are not irrational behaviours. They are rational responses to the incentives created by the system.
That is why simply removing more procedural hurdles is unlikely, on its own, to solve the problem.
We have delivered faster before
We have a very different mindset from the one that characterised earlier periods of NHS capital expansion.
The NHS has previously demonstrated that it can deliver major investment programmes at pace. The Private Finance Initiative programme of the late 1990s and early 2000s transformed large parts of the acute estate within a relatively short period. The Independent Sector Treatment Centre programme moved from launch to operational facilities with remarkable speed by modern standards.
Earlier programmes assumed that some imperfection was the price of delivery.
The current system often behaves as though delay is preferable to imperfection.
Neither programme was flawless. Both carried substantial criticisms, some of them entirely justified. But both operated within a culture that prioritised delivery.
The focus was not on achieving perfect technical, commercial, or contractual outcomes before progress could occur. The focus was on getting schemes moving, accepting that some imperfections would have to be managed during delivery rather than eliminated beforehand.
That culture feels very distant today.
Current programmes often place enormous emphasis on standardisation, technical optimisation, commercial refinement, and iterative assurance. Nobody gets criticised for improving a business case. Nobody gets punished for adding another layer of technical review. Delay is usually safer institutionally than visible imperfection.
The result is predictable. Schemes spend years becoming more robust on paper while very little is actually built.
The question the NHS now needs to answer
What is the NHS capital system designed to do:
· Is it designed to maximise successful delivery?
· Or is it designed primarily to minimise the risk of criticism?
Those are not always the same thing.
The NHS has spent years trying to perfect capital projects. Earlier programmes focused on delivering projects. The distinction matters.
In the next article, I want to explore how NHS capital moved from a delivery culture to an assurance culture, and why that change may now be the single biggest barrier to investment.
I’ll do that by comparing the delivery cultures behind PFI, ISTCs, and current programmes and projects.
