The discussion came at a time of considerable pressure on NHS services following a challenging summer. Waiting times remain a concern across diagnostics, elective care and mental health, while the drive to deliver more care closer to home is placing new demands on healthcare infrastructure. Ageing buildings, maintenance backlogs and access to capital funding add to the challenge.
There was broad recognition around the table that the estate needs to evolve to support these changes, but the conversation was not simply about the need for more investment. Much of the discussion focused on how facilities and the estates themselves could be used more effectively, how investment decisions are made and what could help the NHS deliver improvements more quickly.
Moving beyond reactive maintenance
One attendee described parts of the NHS estate as operating in a ‘run-to-failure’ mode, reflecting the difficulties estates teams face in balancing planned maintenance with immediate operational demands.
With limited resources and competing priorities, urgent issues can understandably take precedence, particularly where infrastructure problems affect clinical services, delay developments or present risks to patient safety. The concern raised was that this can leave too little capacity for preventative maintenance and longer-term planning.
Attendees discussed the balance between investing in new facilities and maintaining existing buildings. While new developments are essential to meeting changing healthcare needs, there was concern that maintenance and refurbishment are not always quick to receive the attention or funding they require. Funding allocated to specific projects can also limit trusts’ flexibility to address other pressing estate priorities.
The role of estates teams in strategic decision-making was another area of discussion. One attendee questioned whether estates professionals have sufficient representation at board level. Others suggested that effective communication with existing board members could be just as important.
For estates leaders, it was about how they can better communicate the impact with the board: the clinical and patient safety risk; operational service performance implications; or estates cost and efficiency. Making the case for estate investment in this language could help ensure infrastructure receives the attention it needs.
Buildings designed for changing needs
The pace of change in healthcare was a recurring theme. One attendee suggested that the way medicine is delivered has changed dramatically over the past 20 years, yet some hospital buildings remain more than a century old.
This raises questions about how facilities can accommodate changing clinical practices and patient expectations. Attendees questioned whether new hospitals should continue trying to accommodate such a broad range of services, or whether greater emphasis should be placed on specialist acute provision alongside care delivered in community settings.
The length of time required to plan and deliver major healthcare developments was also discussed. Clinical requirements and technology can change significantly during a project’s development, creating a risk that facilities are already having to adapt by the time they open.
Procurement and construction approaches formed part of this conversation. One attendee contrasted traditional construction management with design-and-build contracts, questioning whether current arrangements always provide sufficient flexibility to respond to changing requirements and ensure the finished facility meets the needs of clinicians and patients.
The experience of independent healthcare providers was also raised, with attendees noting that facilities designed around a more clearly defined clinical purpose can sometimes be delivered more quickly.
Energy infrastructure presents a further challenge. Some NHS sites face constraints on available electrical capacity, potentially limiting future development without significant upgrades. Attendees questioned how the wider electricity network would accommodate increasing demand as hospitals, transport and other services move towards electrification.
Planning for future patients is equally important. One attendee argued that healthcare infrastructure should not simply reflect the needs of today’s patients, but anticipate how people will access and use services in the decades ahead.
With private providers offering greater choice in areas such as GP access, and healthcare benefits increasingly available through other services, patient expectations may continue to change. The question for NHS estate planning is how to create facilities that can respond to these changes without requiring major redevelopment every time models of care evolve.
Planning and delivering as one system
Another theme was the complexity of planning healthcare infrastructure across a large number of organisations.
With more than 200 NHS trusts in England, alongside integrated care boards and other healthcare providers, coordinating investment and estate decisions across organisational boundaries is not straightforward.
Attendees discussed how governance, approval processes and funding arrangements can affect the speed at which projects progress. While these processes provide important oversight and accountability, there was a view that opportunities exist to make decisions more efficiently.
The NHS response to the Covid-19 pandemic was raised as an example of how quickly services and facilities can adapt when there is a clear and urgent need. Attendees questioned what could be learned from that experience and whether some of the approaches used could inform future estate planning.
Long-term planning was also seen as essential. Healthcare buildings must remain useful for decades, while funding priorities, policy and organisational leadership can change over much shorter periods.
Greater continuity in estate strategies, together with closer alignment between national policy and local service needs, could help organisations make investment decisions that deliver lasting value.
Making better use of what we have
Despite the scale of the challenges, much of the discussion centred on practical opportunities to improve the way healthcare facilities are planned, delivered and used.
Moving more care out of hospitals was one area of focus. Attendees discussed the importance of considering the whole patient journey when planning services, rather than treating individual departments, buildings or organisations in isolation.
Better use of data could help identify where patients experience delays, how they move between services and where changes to facilities or service locations could make a difference.
There was also interest in the potential of existing community healthcare buildings. Reviewing how these facilities are used, their condition and their suitability for different services could identify opportunities to accommodate more care closer to home.
Procurement was another area where attendees saw scope for improvement. Established frameworks can provide a more efficient route to appointing suppliers, subject to the relevant procurement requirements, potentially reducing the time needed to get projects moving.
Modular construction and phased development were also discussed as ways to respond to immediate needs while allowing for future expansion. Rather than waiting for a large development to be completed, some projects may be suitable for delivery in stages, enabling services to benefit from new capacity sooner.
Attendees also considered how greater flexibility in design and delivery could support innovation. Healthcare buildings must meet clinical, safety and regulatory requirements, but there may be opportunities to rethink established approaches and develop facilities that are easier to adapt as needs change.
Turning discussion into action
Closing the evening, Smith reflected on the range of challenges and opportunities raised around the table.
The discussion highlighted the pressures facing NHS estates teams, but also the potential to make progress through better planning, more effective use of existing facilities and closer collaboration between those responsible for delivering healthcare and the environments in which it takes place.
There is no single answer to the challenges facing the NHS estate. Different organisations will have different needs, and solutions must reflect local circumstances, clinical priorities and available resources.
What emerged from the evening was the importance of bringing estates, clinical and operational expertise together earlier in the planning process, considering how facilities will need to function in the future and finding practical ways to deliver improvements without unnecessary delay.
For Smith, the next step is to build on these conversations and explore the practicalities of how we can move some of these suggestions forward, helping to create environments that better support patients, staff and the services they rely on.
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