Research commissioned by the Liberal Democrats spotlights the scale of the challenge facing NHS estates teams. In 2023/24, the health service lost more than 600 days of clinical time to infrastructure failures; collapsing roofs, water leaks and faulty heating and ventilation among the most common culprits.
Over the same period, the estate recorded an average of 22 infrastructure-related risk incidents every single day, and 1,584 of those were serious enough to be graded as critical.
With buildings ageing and the national maintenance backlog now measured in billions, the pressure on facilities managers to keep premises safe, compliant and operational has never been greater.
Against this backdrop, the annual Premises Assurance Model (PAM) submission has become one of the most important governance exercises in NHS estates management.
The PAM is a structured self-assessment that helps organisations judge how well their premises measure up to the regulations, Health Building Notes (HBNs) and Health Technical Memoranda (HTMs) that define a safe healthcare environment. For facilities managers, preparing for it is not a once-a-year scramble. It is a continuous discipline of strategic planning, careful evidence-gathering and methodical execution.
What is the PAM?
Introduced by the government in 2013, the NHS PAM was designed to give estates and facilities teams a consistent, nationally recognised way to demonstrate that their buildings are safe and fit for the delivery of care. It allows a trust to show patients, commissioners, regulators and its own board that robust systems are in place to manage risk, and it provides a common benchmark so that performance can be compared across organisations and investment prioritised where it will do the most good.
The model is built around a set of self-assessment questions (SAQs) grouped into five domains: Safety, Patient Experience, Effectiveness, Efficiency (the use of resources) and Organisational Governance. In practice, the Safety domain is often split into “hard” and “soft” facilities management to reflect the breadth of estates activity.
Each SAQ contains a series of prompt questions, and every question is scored against one of six possible ratings: not applicable, outstanding, good, requires minimal improvement, requires moderate improvement, or inadequate. Those scores are referenced in domain-level and organisation-level summaries, giving the board a clear, visual picture of where assurance is strong and where gaps remain.
The model is built around a set of self-assessment questions (SAQs) grouped into five domains
How the annual process works
The PAM is delivered as an Excel-based workbook, but the real work happens away from the spreadsheet. Most trusts run a series of domain workshops, bringing together subject-matter experts and key stakeholders, including fire, water, medical gas, asbestos and infection, to agree honest ratings for each SAQ.
Crucially, the evidence behind those ratings is not stored in the workbook itself. Instead, the “notes” column simply points to where the supporting documentation lives within the trust’s existing operational systems, and it must be easy to locate, because this is precisely the material the Care Quality Commission (CQC) is likely to scrutinise during an inspection.
Completing the model almost always generates an action plan. Gaps identified in the workshops are logged, prioritised and tracked through the relevant specialist groups and committees until they are closed. The finished assessment, together with its action plan, is then formally presented to the trust board for review and approval.
This board sign-off is not optional. The PAM became a mandatory requirement for Estate and Facilities Management teams within NHS trusts in 2021, and it must be updated and approved by the board every year.
Increasingly, trusts are also expected to share the outcomes of their PAM board report with their Integrated Care System (ICS) and Integrated Care Boards (ICB), reinforcing the link between the condition of the estate and wider system planning. Many organisations run their assessment cycle from late autumn through to early summer, leaving time for internal and external reporting before the next round begins.
Far from being a seal of approval, this is where the process earns its value. Senior leaders carry ultimate accountability for the safety of the estate, and their active engagement (interrogating the ratings, understanding the gaps and backing the action plan) is what gives the assessment real weight. It is also what unlocks the prioritisation and investment needed to close those gaps. A board that engages with the PAM as a genuine governance tool, rather than receiving it as a finished document, sends a clear signal that estate safety is owned at the very top of the organisation.
Celebrate the achievements of your estates, facilities, and project teams
Across the NHS, teams are delivering innovative solutions despite increasing pressures and complex demands. The Building Better Healthcare Awards recognise the people and projects making a genuine difference to patient and staff environments. Click here to enter
Key areas to focus on for PAM readiness
The full readiness checklist is extensive, but six areas tend to make the biggest difference as teams prepare for assessment in 2026:
- Policies and procedures: Have a functioning Quality Management System in place, ideally aligned to recognised standards such as ISO 9001, alongside environmental and health-and-safety management under ISO 14001 and ISO 45001. Review maintenance processes regularly and keep clear, documented maintenance strategies up to date.
- Maintenance strategies and risk management: Build a clear strategy that spans planned, reactive, statutory and condition-based maintenance, and articulate your risk appetite (defined as the amount and type of risk that an organisation is willing to take in order to meet their strategic objectives) across financial, governance and safety dimensions. Integrating this with existing estates and facilities systems streamlines operations and reduces exposure.
- Asset management and compliance audits: Conduct regular asset audits and condition surveys to surface critical maintenance needs, making sure statutory and mandatory tasks are clearly identified and prioritised. A Forward Maintenance Register (FMR) helps track lifecycle replacements and underpin future budget allocations.
- Staff training & communication: Compliance depends on capable people. Make sure key staff understand the framework and the part risk management plays, supported by ongoing training and clear communication of roles, responsibilities and risk assessments.
- Planning and resource allocation: Match resources to strategic goals, confirming the right materials and personnel are available, and use documented plans to level resources and coordinate maintenance across departments.
Evidence and audit trail
Document every strategic decision, risk assessment and maintenance process so it is accessible for audit. This is the foundation of both a credible PAM submission and transparent, defensible day-to-day operations.
Done well, the PAM is far more than a compliance return. It is a structured conversation about risk that turns the daily reality of an ageing estate into a prioritised, board-owned plan for keeping patients and staff safe.
