The Impact of High Levels of Backlog Maintenance on Paediatric Services in UK Acute Hospitals

Introduction

The National Health Service (NHS) in the United Kingdom is facing a mounting crisis: a soaring backlog of maintenance across its estate. By 2023/24, the total cost to clear maintenance issues across NHS trusts reached £13.8 billion, more than doubling in less than a decade. While this problem affects all areas of healthcare delivery, paediatric services—those dedicated to children’s health—are particularly vulnerable. Unlike adult services, paediatrics requires highly specialised environments and equipment tailored to the needs of children and infants. When buildings fail, or repairs are deferred, children bear the consequences in safety, delays, and deteriorating outcomes.

This essay explores how the rise in backlog maintenance in UK acute hospitals is disproportionately affecting paediatric services. Through a review of current data, real-world examples, and sectoral analysis, we will examine the consequences for patient safety, service delivery, staff morale, and the future of child health in the NHS.

The Scale and Nature of the NHS Maintenance Backlog

The NHS maintenance backlog includes all outstanding work needed to keep buildings and facilities operational and safe. This ranges from minor electrical repairs to significant structural issues. The  Health Foundation have reported that the backlog has grown from £6.4 billion in 2015/16 to £13.8 billion in 2023/24. Within this figure, over £7.6 billion is considered “Critical infrastructure risk”—representing maintenance issues that pose a direct threat to patient and staff safety if not addressed urgently.

Some of the most concerning incidents have occurred in leading paediatric institutions. One of the UK’s most renowned children’s hospitals reported a near-catastrophic incident where surgeons were forced to use mobile phone torches during an operation due to a power outage linked to estate failures. This is not an isolated case. Across the NHS, infrastructure problems have resulted in collapsing ceilings, sewage leaks, flooding, and failures in heating and ventilation—all of which can have uniquely severe consequences in paediatric care, where patients are more vulnerable to infection, thermal changes, and environmental stress.

Impact on Patient Safety and Outcomes

Children, especially those with complex needs, are highly susceptible to environmental hazards. Poor ventilation systems can worsen respiratory conditions; failing plumbing can increase the risk of infection; and temperature instability can be dangerous for neonates and premature babies. In acute settings, the physical infrastructure is not just a backdrop—it is integral to care.

Backlog maintenance has led to delayed or cancelled surgeries for children, including time-sensitive interventions. In one case, failure of key systems led to multiple operating theatres being taken offline. For paediatric patients awaiting critical cardiac, neurological, or oncological surgery, even short delays can result in significant health deterioration or loss of life.

The Royal College of Paediatrics and Child Health (RCPCH) has warned that unsafe infrastructure poses a threat not just to health outcomes, but to children’s rights to timely, safe, and effective care. Children are not small adults—their care depends on precise environmental control and equipment availability. A crumbling estate undermines all of these.

Operational Disruption in Children’s Hospitals

In 2023/24 alone, NHS hospitals lost 14,500 hours of clinical time due to estate-related failures which translates to 22 disruptions every single day across England, each with a potential impact on paediatric wards and units. However, it is recognised that these numbers are highly under-reported.

Because children’s hospitals are often part of larger acute trusts, disruptions may affect shared services—such as imaging, labs, or theatres—leading to wider knock-on effects for children’s care. 

Ward closures due to ceiling leaks or asbestos exposure are not uncommon. In some cases, children have been moved into adult wards or outpatient spaces ill-equipped for paediatric care. These ad hoc solutions can have long-term psychological and developmental effects, particularly for children with autism spectrum disorder (ASD), learning disabilities, or trauma backgrounds, who are acutely sensitive to unfamiliar environments.

Staffing and Workforce Challenges in Paediatrics

The paediatric workforce is already under considerable strain, with chronic under-recruitment in specialities like neonatology and paediatric mental health. Working in environments that are physically deteriorating adds to this burden. Leaking roofs, broken lifts, malfunctioning air systems, and inaccessible or outdated staff areas all contribute to low morale, burnout, and attrition.

The British Medical Association (BMA) reports that over 40% of NHS doctors believe the condition of their working environment directly compromises patient care. For paediatric staff—who often work in high-stress, emotionally demanding settings—the additional challenge of unreliable infrastructure can be the breaking point.

Hospitals with deteriorating infrastructure struggle to attract new staff. Junior doctors and specialist paediatricians are more likely to apply to trusts with modern facilities, secure environments, and up-to-date equipment. Paediatric roles are already seen as demanding and high-risk. The lack of safe, supportive environments—physically and professionally—makes these roles even harder to fill.

Financial Implications for Paediatric Services

Postponing maintenance doesn’t save money—it increases future costs. Minor faults turn into major system failures, requiring emergency repairs or complete overhauls. In many cases, trusts are forced to rent external temporary buildings or services while maintenance is carried out—incurring high short-term costs and disrupting care.  Children’s hospitals have spent millions of pounds on stopgap measures. During one winter, after repeated heating failures, one trust had to install temporary generators and heating systems at short notice. Not only is this approach inefficient, but it also diverts funding away from clinical care, training, and innovation.

The capital budget available to the NHS has been insufficient to address the growing maintenance backlog. Between 2021/22 and 2023/24, £707 million less was spent than planned. Paediatric facilities, many of which are based in older Victorian or post-war buildings, are disproportionately affected by underinvestment. Specialist services like neonatal intensive care units (NICUs) and paediatric theatres require advanced technical infrastructure that is expensive to upgrade.

Paediatric care also lacks the same political visibility as other high-profile services, meaning capital investment is often diverted elsewhere. The absence of national targets for specific paediatric surgical waiting times allows structural neglect to persist under the radar.

Unequal Access to Safe Facilities

A growing concern is the regional disparity emerging in children’s care due to infrastructure. Newer hospitals or those built under Private Finance Initiative (PFI) contracts may have better-maintained facilities—but at a financial cost that burdens operational budgets. Non-PFI hospitals, on the other hand, are often older and struggle to secure enough capital to address urgent needs.  This creates a two-tier system where children in some areas receive care in modern, safe environments while others endure unsafe, outdated conditions. Rural or underfunded regions are particularly affected. This threatens the NHS’s founding principle of equity in access and outcomes.

Children from deprived backgrounds are more likely to use NHS services and more likely to rely on their local acute trust for timely care. If these hospitals face critical infrastructure problems, it is the poorest children who suffer most. Delayed surgeries, prolonged hospital stays, and poor-quality inpatient experiences can all deepen existing health inequalities.

Strategic and System-Level Failures

Part of the problem lies in the structure of NHS capital planning. Trusts must compete for limited funding, and projects often require central approval—leading to delays. There is little room for preventative or planned maintenance; most funding goes toward emergency fixes.

Children’s hospitals are caught in this reactive cycle, unable to plan upgrades or expansions proactively. For example, a NICU expansion at a major paediatric trust was delayed for years due to uncertainty over whether the adjacent building would be repaired or demolished—leaving babies in overcrowded units.

While adult services benefit from national frameworks and funding streams (such as elective recovery or cancer pathways), paediatrics often falls between policy priorities. There is no national infrastructure strategy for children’s health services, no protected capital budget, and no unified voice advocating for estates investment in paediatrics.

Potential Solutions and Recommendations

Government should allocate dedicated capital funding to paediatric hospitals and children’s departments within general hospitals. This would ensure that trusts are not forced to prioritise adult services at the expense of children.

Trusts need to prioritise resources to conduct planned, preventative maintenance rather than reacting to emergencies. Managed Service Agreements (MSAs) or hybrid-PFI maintenance models could ensure standards are met without the financial drawbacks of full PFI schemes.

While modular healthcare units provide a practical way to maintain paediatric service continuity during critical estate work. For example, during theatre refurbishment at several trusts, modular operating rooms were deployed to reduce the risk of surgery cancellations. Some children’s hospitals have also used mobile diagnostic units or temporary treatment spaces to support outpatient clinics when main buildings became unsafe. However, all too often temporary solutions become a permanent solution within the NHS, further increasing the burden on budgets and estates staff to maintain. While not a substitute for long-term investment, these options offer a vital lifeline, especially for children with long-term conditions who cannot afford delays in treatment. Government support for modular expansion could help mitigate the impact of backlogs while permanent solutions are developed.

National Strategy for Paediatric Estates

One of the most impactful interventions could be the development of a National Paediatric Infrastructure Plan. This strategy should:

• Map the condition of all paediatric facilities across the NHS.

• Identify high-risk buildings and prioritise repairs based on clinical need.

• Allocate capital funding specifically for paediatric services.

• Ensure all children’s hospitals meet minimum safety and accessibility standards.

• Develop a sustainable maintenance model to prevent future backlog growth.

The lack of a centralised focus on children’s estate issues has allowed years of degradation to get wrapped into the wider infrastructure problems of the NHS. A national strategy would provide the visibility, prioritisation, and accountability needed to turn the situation around.

Embedding Child Health in NHS Estate Policy

Children are too often overlooked in infrastructure planning. Hospital environments are typically designed with adult users in mind and retrofitted for children as an afterthought. This results in poor accessibility, inadequate sensory environments, and a lack of child-specific facilities.Future hospital design must embed child-centred principles from the outset. That includes:

• Family-friendly ward layouts and overnight accommodation.

• Age-appropriate waiting and treatment areas.

• Sensory adaptations for neurodiverse children.

• Child-safe ventilation, lighting, and noise control.

Embedding child health within the New Hospital Programme and all future capital plans would help ensure that new facilities are built not just to function—but to care effectively for the UK’s youngest and most vulnerable patients.

Conclusion

The crumbling infrastructure of NHS acute hospitals is not just an issue of failing bricks and mortar—it is a threat to the quality, safety, and accessibility of paediatric care. As maintenance backlogs surge past £13.8 billion, the impact on children’s services is becoming impossible to ignore. From delayed surgeries to unsafe wards, from burned-out staff to growing health inequalities, the consequences are tangible and urgent. 

Paediatric services rely on precision, planning, and stability—yet are being asked to function in environments that are anything but. In some of the most respected hospitals in the country, surgeries are being conducted by torchlight, vital units are being shut down due to structural failures, and staff are working in demoralising, hazardous conditions.

Addressing the backlog is not just a financial or logistical necessity—it is a moral imperative. The NHS was founded on the promise of care for all, free at the point of need. That promise is being undermined by the physical decay of the very buildings designed to uphold it.

Through targeted investment, strategic planning, and a renewed commitment to child health, the NHS can restore its paediatric services to a standard worthy of the children they serve. But doing so requires leadership, urgency, and the political will to put children at the heart of NHS infrastructure reform.

Until then, children across the UK will continue to face the consequences of a system not failing in intention—but in structure, and in silence.