The NHS estate is one of the largest and most complex public sector property portfolios in Europe, comprising over 24,000 assets across more than 1,200 sites. Many of these facilities are ageing, with 15 per cent of buildings in England constructed before the NHS was founded in 1948.
The estate now has a critical maintenance backlog that is estimated to have reached £13.8 bn in 2023/24 — a figure that has more than doubled in real terms since 2015/16. Of this total, 55% is classified as critical infrastructure risk, meaning failure could result in catastrophic disruption to clinical services. In the same year, over 1,500 critical incidents were reported, with clinical time lost due to infrastructure issues exceeding 600 days. Examples include cancelled surgeries due to electrical faults, chiller failures in operating theatres, and fires caused by water ingress into essential power systems.
The government has allocated over £1 bn to address the most urgent maintenance needs; and efficient execution requires a strategic approach to ensure the delivery models, and controls, are structured to meet the complexity of the challenge, and ensure best value for the individual Trust and the NHS. Modernising the estate and building resilient, future-proofed facilities is essential not only for patient safety but also for meeting NHS performance targets and sustainability goals.
These critical and urgent projects are often executed as part of a Trust’s annual capital plan on short turnaround times alongside other, larger developments that may be taking place at the Trust’s site, including new buildings and large-scale refurbishments. These larger developments must consider the impact and alterations they impose upon the operational environment of the live hospital site.
Delivering in a live environment:
A complex balancing act
The implementation of large-scale projects affects core operational functions, including goods delivery, waste management, smaller capital projects, and other estates services, all of which are critical to maintaining clinical performance and patient care. Temporary access restrictions, site reconfigurations, and increased contractor presence can create logistical bottlenecks, raise operational risks, and reduce flexibility for routine services. Proactive planning, phased delivery strategies, and early stakeholder engagement are essential to mitigating these impacts. Managing business-as-usual alongside project delivery also carries hidden costs, making it crucial to involve facilities management teams from the earliest design stages to ensure continuity and service resilience. By aligning capital project goals with operational realities, Trusts can safeguard patient experience and service quality during periods of transformation.
Delivering major healthcare infrastructure projects within operational hospital environments is one of the most complex challenges facing NHS Trusts today. As the demand for modern, efficient and sustainable facilities grows, so too does the pressure to maintain uninterrupted, high-quality patient care during construction. This dual imperative, generating progress whilst maintaining continuity, requires a carefully orchestrated approach and a delivery structure that recognises and places operational resilience at the heart of capital project planning and delivery.
Protecting the core: Managing the
impact on business-as-usual
When a Trust initiates the development of new acute facilities on an existing hospital site, one of the earliest and most pressing concerns is the potential disruption to the logistics network that underpins the hospital’s daily operations.
These networks are the invisible lifelines of hospital functionality. Goods deliveries, catering supplies, medical consumables and linen arrive daily via tightly scheduled routes, often through constrained service yards located adjacent to busy urban roads — particularly for Trusts based in central London whose estates, over time, have seen expansion and densification that have stretched internal delivery routes to their maximum physical capacity.
Waste collection, pharmacy deliveries and emergency transfers are all equally reliant on unobstructed access. These routes and internal delivery networks have often evolved and adapted over years, or decades, across a changing estate, and any disruption to this finely tuned system can have a cascading negative impact on patient care and staff efficiency. That is why engagement with the Trust’s facilities and operations teams must begin at the same time as discussions with clinical stakeholders and other user groups. The membership and terms of reference of these operational stakeholder groups should be defined early in the project, whilst the project schedule should build in adequate consultation and assurance periods with the relevant operational stakeholder groups.
As the design gains momentum, and the new project or building begins to take shape, the input from operational teams is vital to ensure that the hospital’s core functions remain uninterrupted, and that risks are identified for mitigation plans to be put in place.
Parallel pressures: Delivering BAU
projects during major construction
Whilst large-scale developments often dominate stakeholder attention due to their higher transformational potential and capital spend, NHS Trusts, as a part of business-as-usual operations, continue to deliver a wide range of smaller capital projects in parallel. Individual projects, typically valued below £5 m, are often delivered as part of an annual programme of works. These could include ward refurbishments, service upgrades and essential maintenance works, many of which are driven by the need to address backlog maintenance or meet NHS Net Zero targets.
These projects do not pause during major construction works or new developments taking place elsewhere on the hospital campus. In fact, the seamless delivery of business-as-usual (BAU) capital projects often becomes more urgent, and clinical teams must adapt to temporary constraints and evolving service needs. The coexistence of major and minor projects within the same operational environment requires careful sequencing, coordination, and communication. Without this, the risk of delays, cost overruns, and service disruption increases significantly, with a higher likelihood of the schemes not achieving their objectives.
The equipment challenge:
Logistics of high-impact installations
Projects involving the replacement of large-scale medical equipment such as MRI scanners, CT machines or linear accelerators present their own logistical challenges. These installations typically require road closures, large cranes for equipment movement, and precision scheduling, all of which are complex enough as individual projects — without the added pressures introduced by a neighbouring construction site in the case of hospitals that have major new developments on site.
In many cases, temporary trailer-mounted mobile imaging facilities must be provided to maintain continuity of care. These trailers, often housing CT or MRI units, require additional space within already constrained hospital sites and place further pressure on access routes and utilities.
Another potential challenge arises when a tower crane required for new construction is located near existing MRI suites. The electromagnetic interference from crane operations can disrupt imaging equipment. In such cases, additional shielding and mitigation measures must be embedded in the Construction Environmental Management Plan (CEMP) and agreed with the Trust’s medical physics team. Once construction is complete and the crane is dismantled, MRI systems must be recalibrated to ensure diagnostic accuracy. The impact of cranes on air ambulance service routes, and their exclusion zones on blue light routes, must also be given significant consideration as applicable.
Conversely, tower cranes can also present opportunities. When traditional delivery routes are unavailable, cranes already on site for major developments may be used to lift major equipment into place in the existing site depending on constraints and reach.
This requires close coordination between the project managers for both the equipment replacement projects and the redevelopment project, the principal contractor for the larger scheme, and the various internal Trust teams to align lifting plans with equipment replacement schedules.
The impact of construction on hospital operations extends beyond traffic and logistics. For new developments on existing hospital sites, the design of the new building itself must consider how its delivery and eventual operation will affect adjacent clinical areas, patients flows and visitor egress.
From the earliest stages, the design team, led by a project manager with experience in delivery of healthcare projects and an understanding of the effects that each decision regarding the new building may have on the existing estate, must collaborate closely with Trust stakeholders to evaluate the impact of design choices on BAU operations. Key considerations include:
- Noise, vibration and air quality mitigation: Selecting construction methods and materials that limit disruption to adjacent wards, particularly those housing vulnerable patients and sensitive medical equipment, and ensure appropriate monitoring and escalation methods are deployed.
- Service continuity: Designing mechanical and electrical interfaces that allow for switchover with minimal downtime, ensuring that critical systems remain operational throughout the build.
- Wayfinding and security: Maintaining clear and safe pedestrian flows for patients, staff and visitors during phased construction, while ensuring that security protocols are upheld.
These considerations are not just technical — they are deeply operational. They require a mindset that prioritises the lived experience of hospital users throughout the construction period of the new development.
Waste management:
Planning for the future
Another critical but often overlooked aspect is waste management. Major projects can disrupt existing waste collection routes and storage areas for the live hospital operations teams. Once new facilities are operational, the volume of waste generated also often increases, whilst the space allocated for waste handling may decrease.
To address this, project managers must work with design teams, facilities managers and equipment suppliers to develop bespoke and holistic site solutions. These may include waste compactors designed for narrow spaces, or the installation of resilient bins on lightweight mezzanine structures where ground-level space is limited. Hospital sites located in residential areas must also consider the impact that the current logistics related to waste management have on the neighbours and ensure the solutions related to the new development look to mitigate these concerns as far as possible.
Construction work, both of smaller capital projects and large-scale developments on site can disrupt established fire egress routes, posing risks to safe evacuation and breaching regulatory standards.
To safeguard patients, staff and visitors, the fire safety management master plan must be updated during building works. Following completion of any new development, the plan should also be reassessed and revised to reflect new layouts, occupancy changes and fire safety systems, including any egress routes interfaced from new to existing buildings, ensuring ongoing compliance, resilience and protection.
Finding site space for projects
Ongoing capital projects delivered as part of internal capital programmes are a necessity to sustain the operational NHS estate and address backlog maintenance. Even when a contractor begins a minor project on a congested and constrained hospital site, they still require space for equipment and material storage, welfare facilities and waste skips.
On high density and constrained sites, it is worth exploring options for the principal contractor delivering the main scheme to share welfare and storage facilities with the Trust’s incumbent contractors undertaking smaller projects.
A coordinated construction logistics plan, aimed at coordinating the requirements of all contractors and suppliers involved across the different projects should be considered as part of the overall project implementation strategy.
To overcome all described obstacles and bottlenecks will not be possible without deep and sustained engagement with all stakeholders. From the outset, the success of major projects on existing hospital sites depends not just on the appointed project team’s construction expertise but on a concentrated effort by the entire team to obtain a granular understanding of how the live hospital works, hour by hour, day by day.
Project teams for major projects should also demonstrate their understanding of working in live hospital environments during the procurement phase for professional services and principal contractor roles.
We find that regular coordination meetings with clinical personnel, estates managers and facilities teams offer a forum to quickly and collaboratively share any queries and concerns. By walking the site, observing routines and listening to concerns, we can anticipate and respond to challenges early. This ‘business-as-usual-first’ mindset helps build trust between the project team and the wider stakeholder group, enabling swifter decision-making and reducing the risk of costly project delays.
We have often worked with Trusts to ensure works on major on-site developments did not encroach on BAU project areas. In some cases, we coordinated joint use of contractors’ access and Trust egress routes to minimise disruption and cost. This level of coordination in achieving its aims requires not only technical skill but also empathy, flexibility and a shared commitment to the ultimate goal of effective patient care.
Embedding operational resilience
Operational resilience must be embedded into every stage of the project lifecycle, from strategic briefing/business cases and concept design through to construction and commissioning. This engaged approach ensures that the delivery of new healthcare infrastructure does not compromise the continuity of care or the day-to-day functioning of NHS services.
Early in the process, project teams should facilitate operational workshops that bring together clinical, estates and facilities staff. These sessions help map out critical workflows and identify potential pinch points that could be affected by construction. Live simulation exercises, including real-time walkthroughs and scenario planning, are also valuable tools for testing proposed phasing and access arrangements before works begin.
Aligning the construction programme with the Trust’s operational calendar is essential. Known timeline points, such as major equipment replacements, or planned service reconfigurations, must be factored into the delivery schedule. Dynamic risk registers should be maintained throughout the project, capturing operational risks alongside traditional construction risks. These registers must include clear ownership, mitigation strategies and escalation pathways to the executive board.
Project managers can add significant value by treating operational resilience not as a constraint but as a core deliverable. Their role includes translating the Trust’s strategic objectives, such as delivering care efficiently, safely and sustainably, into tangible design and phasing decisions. Project managers should function as advocates for operational concerns, ensuring that every design choice — from façade layout to waste flow — is considered through the lens of real-world hospital operations.
Strong project leadership also means fostering collaboration. Weekly site liaison meetings with estates, FM, clinical leaders, ward staff, infection control and communications teams help maintain alignment. Shared calendars, visible phasing maps and digital dashboards can support transparency and allow for the routine review of both planned and unplanned impacts.
All healthcare projects are increasingly shaped by the NHS’s commitment to sustainability and the Net Zero agenda. This adds another layer of complexity to the delivery of infrastructure within live environments. Temporary works, for example, must be designed with reuse and minimal waste in mind. Construction logistics plans must consider emissions, noise and air quality impacts on patients and staff.
At the same time, the long-term operation of the building must support sustainable practices, from energy-efficient systems to flexible layouts that can adapt to future clinical needs. Engaging operational teams early ensures that sustainability is not just a design aspiration but a lived reality.
Lessons learned and looking ahead
Delivering major projects within operational hospital sites is never straightforward. Yet with the right approach, it is possible to balance progress and continuity in a way that enhances both. Success depends on early engagement, shared goals/objectives, open discussions about previous projects, holistic thinking and a commitment to clear, continuous communication.
Operational teams must be involved from the outset; not as a late-stage check, but as integral contributors to the design and delivery process. Understanding the full ecosystem of hospital activity, beyond the immediate construction footprint, allows project teams to anticipate challenges and build in the flexibility needed to respond to the unexpected.
At the heart of this approach is a people-first mindset. Hospitals are places of care, and every decision, from phasing to access routes, must support that mission. Project managers should play a vital role in translating the Trust’s strategic objectives into practical design and delivery solutions. They advocate for operational realities, ensure risks are actively managed and lead collaborative forums that bring together estates, clinical, FM and communications teams.
The Turner & Townsend healthcare project management team has decades of proven experience working in live hospital environments. As the NHS estate continues to modernise, the ability to deliver complex projects without compromising the delivery of care will be a defining capability. By placing operational continuity at the centre of delivery, we help Trusts ensure that today’s improvements do not come at the cost of tomorrow’s care.