The NHS estate is under immense pressure — and not just metaphorically. While staff and Trusts continue to work tirelessly to provide the care patients deserve, ageing buildings, deteriorating infrastructure and a growing backlog of maintenance make this increasingly challenging, affecting patient safety, staff wellbeing and overall system efficiency.
Yet with the introduction of the 10 Year Infrastructure Strategy, there may finally be an opportunity to turn the tide. This long-overdue shift from reactive repairs to strategic investment offers a pathway to greater resilience and better outcomes. So, will it provide the funding and relief the industry has been hoping for?
Infrastructure investment at a glance
At a glance, the strategy will provide:
- £70 bn from 2025-26 to 2029-30, for targeted infrastructure replacement, maintenance, critical safety and the wider Department of Health and Social Care (DHSC) portfolio.
- £24 bn invested in the New Hospital Programme over the next 10 years.
- An additional £49 bn, from 2030-31 to 2034-35, for the New Hospital Programme, for wider repairs of hospital infrastructure.
- Over £6 bn per year, from 2025-26 to 2034-35, for maintenance and repair of the NHS estate with investment targeted to reduce the level of critical infrastructure risk and eradicate Reinforced Autoclaved Aerated Concrete (RAAC), the unsafe lightweight concrete still present in parts of the NHS estate, entirely.
With NHS backlog maintenance costs reaching a record £13.8 bn in 2023/24, it’s clear that this is not just the physical buildings — it’s about safety, functionality and ultimately, saving lives.
The task ahead requires system-wide thinking, collaborative working and long-term planning. So, what does delivery look like in practice — and what are the risks?
Understanding the risk landscape
Some risks may seem minor on paper — like an ageing transformer — until you consider the impact of sudden power loss in an operating theatre.
In a healthcare setting, what would be manageable in other environments becomes a much more serious matter. HVAC failures can worsen infection risk. Lift malfunctions can trap patients and delay emergency transfers. Outdated medical gas systems can interrupt oxygen supply.
In many cases, the greatest threat lies in estates that lack resilience altogether — buildings with no backup systems or redundancy in place. This puts even more pressure on the need for proactive planning.
To manage this, a national programme of infrastructure risk assessments should be prioritised. Supported by experienced delivery partners and driven by data, this approach would enable a consistent and reliable understanding of estate condition across all Trusts. Crucially, it would help to shift the system from reactive firefighting to planned resilience — allowing NHS organisations to prioritise high-risk areas with confidence and transparency.
However, this can’t be done in isolation. It requires shared learning, collective ownership of risk and a unified approach to estate safety.
Beyond quick fixes
There needs to be a fundamental shift in how we view NHS estates. Backlog funding has often been used as a plaster — quick wins for urgent problems — but these rarely deliver sustainable value. True resilience demands longer-term thinking.
Planning must move away from reactivity. Estates should be clinically driven, future-focused and above all, patient-centred. Each repair, upgrade or investment must be seen through the lens of care outcomes. Recurring repairs don’t just pose risks to patients — they undermine productivity and staff morale. It’s time to ask: what is the long-term cost of short-term thinking?
The solution lies in integrated, service-led estate strategies. These should be developed in parallel with clinical strategies, shaped by local need and supported by real-time asset tracking. Digital tools can help monitor condition, schedule maintenance and highlight performance issues — all contributing to greater reliability and efficiency.
Early contractor involvement will also be essential. By bringing contractors into the fold early, Trusts can draw on practical insight into buildability, logistics and cost, ultimately leading to better-informed decisions and fewer delays. Strategic master planning — grounded in real operational input — ensures that everyone from clinicians to designers is aligned from the start, helping projects begin with clarity and confidence.
Embedding these principles is central to planning for resilience, ensuring that the NHS estate can adapt to future pressures while continuing to deliver safe, high-quality care.
Delivering in live environments
Unlike commercial buildings, NHS hospitals can’t close their doors at 5pm. Critical works must take place around active clinical services, and often severely unwell patients, making the stakes far higher, and the margin for error far smaller. This makes careful, anticipatory planning a non-negotiable part of resilience, balancing infrastructure needs with uninterrupted patient care.
This unique challenge demands precision planning. Risk assessments must be carried out at the earliest possible stage, with clear protocols in place for infection control, air quality and fire safety. Involving stakeholders such as fire officers, clinical leads, maintenance and infection prevention teams from day one helps build practical, manageable delivery plans that protect patients while work takes place.
Where possible, works should be phased to minimise disruption — with noisier or more intrusive elements scheduled during off-peak hours. Communication is equally critical. Staff, patients and contractors must all be kept informed, ensuring expectations are aligned and any potential issues can be addressed early.
One of the most effective ways to navigate these complexities is by partnering with a project management consultancy that specialises in healthcare environments. These specialists understand the challenges of delivering in live clinical settings — from safety standards and infection control to procurement and compliance. Their involvement often leads to better planning, faster delivery and more efficient use of resources.
Just as importantly, they bring sector-specific knowledge. They know where projects go wrong, and how to avoid those pitfalls. From regulatory permits to innovative design solutions, their input can help Trusts balance risk, cost and care priorities more effectively. Their expertise ensures that works in live environments strengthen, rather than compromise, the long-term resilience of healthcare facilities.
Governance, compliance and value
Design governance in healthcare is often misunderstood as red tape, when, in reality, it’s one of the most powerful tools for protecting both patient safety and programme budgets. Without firm control over scope, standards and change, projects can quickly spiral, either through avoidable costs or through designs that fail to support care delivery. Strong governance is therefore not an administrative burden, but a critical foundation for resilient estate planning.
Critically, value must be measured through outcomes, not just cost per square metre. A facility that’s cheap to build but inefficient to operate, or clinically unfit, doesn’t offer true value. The focus should always be on how space performs — for staff, patients and future demand.
Compliance plays a huge role here. Health Technical Memoranda (HTMs) and Health Building Notes (HBNs) should not be seen as guidelines to interpret — they are non-negotiable standards that define what good looks like in the NHS. They cover every aspect of healthcare design and engineering, from ventilation and water safety to room sizes and clinical flows. Adhering to these from the outset reduces the risk of costly redesigns, delays and safety breaches.
Robust governance frameworks should be in place to manage design evolution and mitigate scope change. This includes clear roles and responsibilities at each RIBA stage, appropriate reporting structures and formal change control processes to manage adjustments. Ensuring decisions are evidence-based and clinically informed keeps projects aligned with core objectives. In doing so, governance frameworks safeguard both the immediate functionality of facilities and their capacity to serve future generations, a cornerstone of resilience.
Ultimately, good governance ensures the NHS gets what it actually needs — not just what’s affordable or deliverable in the short term.
At its heart, infrastructure isn’t about buildings — it’s about people. The clinicians pulling back-to-back shifts. The porters navigating corridors at 3am. The patients relying on a clean, safe and welcoming space during some of the most vulnerable moments of their lives.
The physical environment plays a central role in both care quality and staff wellbeing. Intuitive, well-designed spaces don’t just streamline clinical delivery, they make staff feel supported, respected and safe. That can have a direct impact on retention, morale and patient outcomes.
By involving clinicians in the design process, we can create environments that reflect how care is actually delivered. Their insight ensures layouts are logical, workflows are intuitive, and patient safety is prioritised at every touchpoint. Involving staff directly in planning ensures that resilience is built into every corridor, ward and workspace — not as an abstract concept, but as a lived reality.
Sustainability also can’t be left behind. NHS infrastructure must support Net Zero goals as well as operational performance. From insulation and materials to energy systems and renewables, sustainable design isn’t just a climate necessity, it’s an economic one. Smarter buildings cost less to run and are better equipped to adapt to future needs.
Infrastructure as a strategic enabler
NHS infrastructure is not background; it’s the foundation on which every clinical decision is made. Every diagnosis, treatment and recovery depends on a safe, functional and supportive environment. By treating infrastructure as a strategic enabler — not just a capital cost — we can embed resilience into the health service from the ground up.
That means planning smarter. Engaging stakeholders earlier. Designing for long-term performance rather than short-term gain, and, most of all, building with purpose.
This isn’t just about bricks and budgets, it’s about building environments that enable life-saving care, support hard-working staff and stand up to future pressures. From climate resilience to digital readiness, today’s decisions shape tomorrow’s outcomes.
The Spending Review offers a rare window of opportunity. Let’s use it to shape healthcare environments that are safer, smarter and ready for whatever the future brings — not just for the system, but for every person who depends on it.