The NHS 10 Year Plan sets a clear direction for healthcare. It calls for more care to be delivered closer to home, greater use of digital services and a stronger focus on prevention. Together, these changes aim to improve patient outcomes and create a more sustainable NHS.
The challenge is that much of the NHS estate was designed for a very different model of care. Many organisations are also managing ageing buildings, growing backlog maintenance and constrained capital budgets. Across the NHS, the hospital backlog maintenance bill has more than doubled since 2015 to almost £16 billion. More than 4,100 estates-related incidents were recorded in 2024/25. In primary care, one in five buildings pre-date the foundation of the NHS itself, with many no longer suited to modern models of care.
For most organisations, replacing large parts of the estate is neither affordable nor achievable within the lifetime of the Plan.
So how do NHS organisations adapt the estate they have today to support new models of care while planning for the facilities they will need tomorrow?
That is now one of the defining challenges for NHS estate leaders.
The starting point is understanding how services are delivered today
The starting point is understanding how services are delivered today, where the estate creates barriers and what facilities future models of care will need. Only then can organisations identify the changes needed to support that transition.
Making room for care in the right place
One of the central ambitions of the NHS 10 Year Plan is to move more routine care into neighbourhood settings. This allows valuable acute space to be reserved for activity that genuinely needs a hospital.
That shift is already underway. Virtual consultations, remote monitoring, community diagnostic centres and integrated neighbourhood teams are changing how patients access services.
We've seen the benefits through our work on the Devizes Health Centre and Trowbridge Integrated Care Centre in Wiltshire. These developments brought together primary care, community health services, outpatient clinics and diagnostics in integrated facilities designed around patients rather than organisations. The result is better access, stronger teamwork and buildings that can adapt as services continue to evolve.
As demand for acute space changes, NHS organisations have an opportunity to rethink how hospital buildings are used. Areas previously occupied by routine outpatient activity can be repurposed to support new clinical services, improve patient flow or accommodate growing demand for specialist care.
NHS organisations must now balance two priorities
Estate leaders have an important role to play. They provide evidence on estate condition, use and building performance. That helps organisations decide where services should be delivered and how existing buildings can support future priorities.
Creating the environments specialist care now demands
While some routine activity is moving closer to home, some specialist care is moving in the opposite direction.
The NHS 10 Year Plan, alongside advances in cancer care, genomics and advanced therapies, is creating demand for highly specialised environments. These include laboratories, radiotherapy suites and research facilities. They need advanced technology, specialist equipment and close collaboration between clinicians, researchers and industry partners.
We're currently supporting a leading acute trust in central London as it develops new facilities for specialist care. The project will increase capacity and create environments that support new technologies and complex treatment.
This reflects a wider trend across the NHS. As specialist services become more concentrated, purpose-designed facilities bring together the expertise, technology and research needed to deliver increasingly complex care. For patients, this means earlier access to innovative treatments, more consistent standards of care and better clinical outcomes. These environments also help NHS organisations attract leading clinicians and researchers, strengthening specialist centres of excellence.
NHS organisations must now balance two priorities. They need to identify where routine activity can move beyond the hospital while investing in the specialist environments that modern healthcare demands.
Successfully managing this transition will need careful estate planning. It will also need investment. With capital budgets under continued pressure, estate leaders need to think differently about how transformation is funded.
Funding transformation
The government's recently published 10 Year Capital Plan is a welcome commitment to modernising the NHS estate. It includes increased capital investment, funding to expand and modernise GP surgeries, and long-term investment to tackle backlog maintenance.
However, the pace of change across healthcare, technology and the estate means organisations cannot rely on capital programmes alone. Estate leaders need to act now to support new models of care while planning for future investment.
Forward-looking organisations are increasingly viewing their estates as strategic assets that can help fund and enable transformation.
Research and innovation partnerships provide one opportunity. Cancer Research UK's £173m investment at the University of Cambridge and the Barts Life Sciences Cluster show how partnerships between healthcare providers, universities and industry can create world-class facilities while attracting external investment.
There are opportunities within existing estates too. Better use of underused buildings, development partnerships and commercial opportunities can all generate value to support future investment.
Turning strategy into action
Delivering this scale of transformation requires a structured approach.
First, understand future demand. Estate strategies should reflect the direction set by the NHS 10 Year Plan rather than historic patterns of activity.
Second, understand how existing assets perform. Assess condition, use, suitability and how well buildings support clinical services.
This often reveals opportunities that are easy to miss. During one review, we found clinical rooms assigned to individual teams for only part of the week. They stood empty the rest of the time. Related services were also spread across the building, creating a fragmented experience for patients.
Third, improve how space is used. This may involve bringing services together, repurposing space or supporting new models of care.
For the above example, we introduced shared room booking and reorganised services so related teams worked alongside one another. Patients could access care in one place, creating better use of space, a better patient experience and extra clinical capacity without new buildings.
We introduced shared room booking and reorganised services so related teams worked alongside one another
Fourth, develop a clear investment strategy. Organisations need a roadmap that balances short-term improvements with long-term estate priorities.
Finally, make sure the right delivery capability is in place. Estate transformation brings together clinical strategy, operations, finance and programme delivery. Few organisations have every specialist skill in-house, so many seek support with demand modelling, strategic asset management, commercial advice and programme delivery.
The organisations making the greatest progress bring together the right skills, evidence and partnerships. That gives leaders the confidence to make informed decisions.
Delivering the future NHS
The NHS estate will play a defining role in delivering the ambitions of the 10 Year Plan.
By making better use of today's buildings while planning for tomorrow's investment, estate leaders can enable new models of care and improve patient outcomes. They can also create healthcare environments that remain fit for the future.
The organisations that succeed will see estate strategy as a catalyst for transformation. Their estates will help deliver better care today while creating the foundations for a stronger and more sustainable NHS tomorrow.
