Managing the NHS estate: a radical rethink

For decades, the NHS has struggled with ageing, inefficient buildings, fragmented funding, and bureaucratic delays that have slowed construction within the health sector, leaving hospitals and health centres operating below their potential, and adding pressure to both staff and patients.

Many NHS buildings were designed for a very different model of care when services were more centralised and the demands on facilities were far less complex. As clinical services have evolved, estates have often struggled to keep pace, leaving NHS staff working in environments that were never designed for modern healthcare delivery.

These inefficiencies come at a significant financial cost. Poor energy performance and outdated infrastructure increase operational expenditure, diverting valuable resources away from frontline care. Beyond energy costs, ageing buildings also affect the way hospitals operate day to day. Layouts that restrict patient flow and limited diagnostic capacity can all reduce the efficiency of care delivery. And when buildings limit how services function, the impact is felt not only in operational costs but in patient experience and staff productivity.

This is leading the NHS to a radical rethink of its estate. Last year, the government unveiled an ambitious ten-year plan for the NHS to secure its long-term future. Critical to the success of this plan will be the hospital buildings and healthcare centres where care happens, with three key reforms identified: a shift from hospital to community care, from analogue to digital systems, and from sickness to prevention.

Cost savings through estate management

Understandably, for financially stretched NHS Trusts, estate investment has historically been viewed as a cost to be managed — a cost which takes away funding for patient care. Maintenance, building compliance, and refurbishment have often been treated as isolated capital exercises, disconnected from clinical priorities and patient outcomes.

However, there is now growing recognition that estate investment, particularly decarbonisation and energy efficiency upgrades, can deliver measurable cost savings. These savings can be reinvested into patient care, creating a virtuous cycle where infrastructure improvements directly support clinical delivery.

This shift in thinking reflects a broader understanding that healthcare estates are not simply operational assets but critical components of the care pathway. The design, layout, and performance of buildings can influence everything from waiting times and diagnostic capacity to staff wellbeing and infection control. When estates are planned strategically, they become active enablers of better clinical outcomes rather than passive infrastructure.

In conversations with Trusts, contractors are already seeing the way the ten-year plan is changing the landscape and shifting perspectives of how estates must function. There is a growing recognition that hospital buildings and healthcare centres can be used as strategic enablers of better health outcomes and a better patient experience.

The New Hospital Programme will deliver important new capacity, with thirty schemes approved under the programme. However, most Trusts will continue to operate from existing buildings for decades to come. With more than 10,000 buildings and a maintenance backlog estimated at £16bn, if the NHS is to meet these new ambitions, its existing estate must evolve, be upgraded, and become the backbone of patient care.

This shift in thinking is perhaps not surprising considering then prime minister Keir Starmer’s advice to the NHS last summer ‘reform or die’. Under the ten-year plan, funding for Trusts is increasingly being linked to health outcome success, with those who successfully deliver granted further autonomy. This will enable Trusts to make estate decisions with a clear focus on patient and population health, rather than being bound by red tape or short-term cost constraints. Improving patient flow, co-locating services, and creating environments that support patient throughput will become essential to meeting Trust performance measures and securing additional funding.

For many Trusts, this means finding ways to modernise estates while services continue to operate at full capacity. Hospitals cannot simply close wards or diagnostic departments while upgrades take place. Delivering improvements within live clinical environments requires careful planning, close collaboration between healthcare teams and industry partners, and construction approaches that minimise disruption to patient care.

Longer-term partnerships between Trusts and the industry will not only be possible but will be essential to meeting the new measures. Operational certainty will become critical, as any disruption to patient flow or service delivery carries real consequences. This places a premium on industry partners who can deliver complex upgrades within live hospital environments safely, efficiently, and predictably.

Decarbonisation: a powerful tool

Decarbonisation is emerging as one of the most powerful tools available to Trusts. Despite the NHS’ commitment to achieving Net Zero by 2040, on the ground, sustainability initiatives often compete with urgent operational priorities and building compliance issues. But integrating energy efficiency and carbon reduction into estate improvements can deliver real benefits.

Long-term industry partnerships can help Trusts implement proven solutions and bring cross-sector learning, from upgraded building fabric and modernised plant systems to smart energy management technologies that reduce consumption, lower utility bills, and create recurring financial savings. Contractors can show Trusts where the approach is already delivering results, even within other sectors, such as at the BAM-built Woodmill and St Columba’s High School in Fife, where energy bills have been cut by £433,392 — a reduction of 48 per cent in the first year of operation.

The focus is shifting from reactive, piecemeal interventions to strategic, outcome-driven planning. Multi-year funding allocations, combined with a clearer link between performance and investment, are allowing Trusts to plan with confidence. Projects can now be phased to maintain service continuity, reduce disruption, and deliver measurable improvements for patients and energy efficient upgrades can be embedded seamlessly alongside other improvements, generating savings that free up resources for frontline care.

Even more exciting is the potential to think beyond the walls of hospitals. Healthcare facilities are often located in the very communities experiencing the worst health outcomes. There is a huge opportunity here for industry to apply its social value expertise, to ensure investment in these buildings creates wider benefits from co-located services that improve access to care, to green space, employment opportunities, and community wellbeing.

The NHS’s buildings are not just structures — they are tools to deliver better care. By investing in decarbonisation and modernisation, Trusts can reduce costs, improve resilience, and unlock funding that can be reinvested directly into patient care. With thoughtful planning, industry support, and integrated decarbonisation, they can switch from being a source of frustration into a foundation for transformation.

Case study:Expanding diagnostic capacity through community-based care

In Plymouth, BAM is delivering a new Community Diagnostic Centre (CDC) for University Hospitals Plymouth NHS Trust, designed to bring essential diagnostic services closer to the communities that need them most.

Located in the heart of the city, the three-storey facility will provide around 91,000 diagnostic tests each year, including CT, MRI, X-ray, echocardiography, ECG, EEG, and audiology services. Each floor is organised around specific diagnostic functions, with dedicated reception and waiting areas designed to improve patient flow and the overall experience.

The centre forms part of the Trust’s wider Future Hospital Programme, which aims to decentralise services and reduce pressure on acute hospital sites by delivering care closer to where people live. By locating diagnostic services in a highly accessible city-centre location, the centre will make it easier for patients to attend appointments, particularly those who may face barriers travelling to larger hospital campuses.

CDCs are designed to allow patients to receive multiple tests in a single visit, helping to accelerate diagnosis and treatment. Increasing diagnostic capacity in this way supports earlier detection of conditions such as cancer and cardiovascular disease while helping the NHS reduce waiting times and improve patient outcomes.

Projects like the Plymouth CDC demonstrate how investment in modern healthcare estates can support new models of care while improving accessibility for local communities.

Case study: The Eden project provides green space in communities that need it most

Royal Liverpool University Hospital is the first project being delivered through our new partnership with the Eden Project. The collaboration demonstrates how healthcare developments can create space for nature in the very communities that need it most.

Plans are underway to transform part of the former hospital site into a nature-diverse garden and public space, replacing demolished buildings with landscaped green areas to support wellbeing for patients, staff, and local residents.

The scheme will introduce native planting to support pollinators and biodiversity, alongside quiet spaces for reflection and relaxation within the hospital campus. Safe pedestrian and cycle routes will also play a key part in improving connectivity across the site, creating a welcoming green environment in the heart of the city.

Located within an inner-city area where communities face significant health inequalities, the project demonstrates how investment in healthcare estates can deliver wider social value. By turning part of the hospital campus into accessible green space, the development shows how modern healthcare infrastructure can support both clinical outcomes and community wellbeing, bringing nature back into urban environments where it can have the greatest impact.

Case study: Upgrading ageing hospital infrastructure at Royal Cornwall Hospital

At Royal Cornwall Hospital in Truro, we are working with the Trust to deliver a phased programme of fire safety and estate upgrades within parts of the hospital that date back to the 1960s and 1970s. The works are focused on bringing critical infrastructure up to modern safety standards while allowing the hospital to continue operating around the clock.

The programme includes the installation of new fire walls, fire doors, fire dampers, and upgraded alarm systems across a series of wards and key hospital corridors. Flexibility and close collaboration between the Trust, BAM, and clinical teams is essential on the scheme. Wherever budget allows, additional improvements are carried out when wards are decanted, including new flooring, upgraded utilities, new clinical sinks, and redecoration.

The programme is being delivered in ten phases, with one ward upgraded at a time. Again, flexibility and collaboration are key — when the next ward in the programme is not available due to shifting clinical priorities, an alternative area is upgraded, such as a bed store.

Delivering these important works in a live hospital environment presents significant logistical challenges. Construction is taking place alongside operating theatres, cancer services, and immuno-suppressed wards, requiring strict infection control procedures and carefully managed construction sequencing. Each work area is sealed behind positively pressurised lobbies, with dedicated hygiene operatives and cleaning teams maintaining clinical standards.

Projects like Royal Cornwall highlight the complexity of modernising the NHS’s existing estate. Through close collaboration with the Trust and a largely local supply chain, upgrades can be delivered safely and flexibly while hospitals continue to provide essential care.