Translating estates risk into strategic decisions

NHS estates are under pressure from ageing infrastructure, a rising maintenance backlog, and constrained capital investment, leaving organisations operating in a cycle of reactive interventions and growing risk. While these risks are often well understood at an operational level, they are not consistently translated into structured, deliverable investment programmes. Blanca Beato Arribas, associate, Ryan Elliott, director, and Andy Vernon, director and healthcare sector lead from building consultants firm Hoare Lea explore how a systematic data analysis and risk-led approach can support better decision-making, reduce long-term risk, and improve environments for patients and staff.

Despite the government’s announcement to invest in hospitals in the New Hospital Programme (NHP), the programme only addresses 20 per cent of England’s Trusts, leaving many existing Trusts in England, Scotland, Wales, and Northern Ireland to continue to deal with an ageing estate and increasing backlog risks.1 This raises the need to avoid the NHS evolving into a two-tier system, where some organisations benefit from new infrastructure while others continue to manage ageing estates.

Backlog maintenance persists not because risks are unknown, but because technical estates intelligence is insufficiently translated into structured, multi-year Board-ready investment programmes.

Estate teams face significant pressures, from day-to-day operational pressures to keep clinical operations ongoing, fragmented data, and continuous pressure to deliver projects under stricter procurement, building safety act (fire) regulations, and reduced budgets. As a result, small-scope projects designed to minimise immediate clinical risks are more likely to be delivered, leading to increasing overall risks, placing additional strain on existing infrastructure, raising maintenance costs, and impacting sustainability goals in the long run.

Analysing data from multiple sources, however incomplete — including estates risk databases, backlog items, and six facet surveys — and applying NHS backlog risk categorisation to the results, is not a straightforward exercise. In addition, a large amount of information sits with individuals and is not formally captured. However, when information is approached in a systematic manner it can unlock solutions that address the backlog. It can then support the development of multi-year, deliverable programmes of work. These enable estates teams to present data clearly and in an evidence-based manner, alongside multiple investment scenarios to board level decision makers, supporting tangible risk reduction over time. This improved visibility also allows estates teams to engage more effectively with the supply chain, providing greater certainty around future workstreams and enabling partners to plan, invest, and support delivery over the longer term.

The persistent backlog problem

The NHP, originally set to deliver 40 hospital schemes by 2030, has been welcome news in the NHS. NHP is being delivered across multiple waves, with only a limited number of schemes currently in construction, and many remain in early planning stages. Project delays and programme reprioritisation means that some trusts will not see a new hospital complete in 20 years, while others are not on the NHP list at all. This situation leaves many Trusts in charge of maintaining ageing estates, where risks continue to increase, systems are under constant strain, and funding constraints limit the ability to deal with increasing backlog costs.

Existing NHS England hospitals are facing a maintenance backlog that has grown from £1bn in 2015 to £15bn in 2026,2 with critical repairs and costs both on the rise, while funds to address this backlog remain constrained. The most critical issues include failures that can lead to significant clinical disruption, such as heating outages, flooding, or infrastructure failures requiring the closure of wards or relocation of patients.

Constant financial pressure

Estates teams are under constant pressure to ensure that failing systems continue to work without impacting clinical areas or operations. Although teams are knowledgeable about the systems, the development of a programme of works for the next financial year (or years) tends to be decided under time constraints and with possible area-of-expertise bias.

Projects drafted for the following financial year 
are often impacted by delays in budget allocation and procurement regulations, which severely affect project completion deadlines, as projects cannot commence 
until budget is released. Project teams are often closing out works from the previous financial year, while beginning to scope new schemes without confirmed budgets. Once funding is released, these teams are under pressure to complete projects in a reduced timeframe. Additional fire safety requirements under the Building Safety Act (BSA) can introduce further delays and significant costs to projects, which may result in Trusts delaying much needed planning and projects in high buildings.

As a result, project scopes are reduced, increasing pressure for hospital groups to approve or derogate modifications that are not fully aligned with Health Technical Memoranda. In parallel, policies and procedures are not always be consistently applied, introducing tension between maintenance and project teams.

Short-term solutions

The reduction in project scopes, combined with the need to remediate problems within short timeframes, leads to the implementation of short-term solutions. While necessary in the moment, these solutions introduce additional risks, increase energy consumption, place an additional load on existing infrastructure, and work against long term sustainability objectives. A common example is heating systems; full system replacement may not be possible due to timeframes (summer months) and budgets, and temporary electrical heaters are introduced to ensure patient comfort and maintain safe care environments. However, this increases electrical costs, strains the electrical capacity of the building systems, and introduces a new fire risk.

The impact of projects on clinical areas also needs to be taken into consideration. Additional measures and procedures, not typically required in other types of construction, are necessary in hospitals to ensure patient safety. Clinical operations must continue, projects may need to be scheduled at night, and construction activities such as dust generation can pose significant risks to patients. There is also an increased risk when new systems are integrated with existing older infrastructure such as water distribution or fire safety alarms.

Pressure to complete projects on time due to clinical needs leads to poor soft landings, resulting in incomplete handover to maintenance teams, incomplete asset lists, and lack of maintenance, which introduces further problems in the future. Miscommunication between maintenance and project teams, or the by-passing of procedures in an occupied hospital, significantly impacts the whole estate. Risks that were previously contained at asset level will escalate to system wide issues if not properly managed.

Finally, any surplus budget which emerges at the end of the financial year, driven by the need to ‘break even’, cannot always be utilised effectively due to project timescales and delivery constraints.

The cumulative effect is a continuous cycle of constrained budgets, short-term interventions, rising risk, and sustained pressure on estates teams to maintain safe and operational environments for patients and staff.

Governance and translation of technical risk

While risks are often clearly identified, the mechanisms to act on them remain constrained. Estates risks are often clearly identified and well known by the maintenance teams. However, they are presented across multiple reports and datasets, which are often incomplete, including six facet surveys, statutory compliance records, Trust risk databases, specialists’ reports, Authorising Engineer reports, and staff-held knowledge.

Many hospital systems and processes exist to record risks and non-compliances; however, processes to rectify them are often less developed or require a high level of approval, complicating corrective actions.

Asset capture and system updates can be further affected by poor soft-landing of projects, resulting in unknown or unmaintained assets. Over time, system information can become outdated, including asset registers and infrastructure drawings. This complicates maintenance and increases risks where assets are not properly maintained. In some cases, teams rely on historical knowledge or incomplete records, while new projects have to start using outdated information, leading to delays and increased costs. This data fragmentation complicates maintenance, compliance analysis, and risk assessment for already overstretched estates teams.

Integrated Care Boards have a balancing act to determine the risks and needs of all organisations within their control and the impact on service delivery and operational pressures. As a result, estates decisions are not always made on technical risk alone, but within a wider funding context.

At the same time, complex technical risks and findings are often simplified through layers of committees and reporting to a level that does not fully represent their severity or their potential consequences. When information reaches the Board, which often has no estates or technical representation,3 risks may not be fully articulated, limiting informed decision making and resulting in underinvestment in estates priorities.

The way forward

A shift is required, from identifying technical risks to translating them into multi-year programmes of work, demonstrating that estates teams, often perceived primarily as an operational function, play a critical role in strategic decision making.

This requires an evidence-based approach that allows for decision-makers to examine options on an objective basis. In a reactive and high-risk environment there is a tendency to focus on solely big, high-risk issues that can become emotive but are also very difficult to implement. We have seen in many cases where this paralyses decision-making and progress resulting in budgets not being spent and projects not being delivered.

When a methodical approach is implemented that removes human bias and looks at what the best path forward is based on facts and data, meaningful progress can be achieved. This can mean challenging some pre-conceptions around how to address a problem such as backlog risk, specifically that often a mix of high risk-high effort projects paired with some easy wins is far more likely to make meaningful progress over time, as opposed to a focus on only the largest projects.

In terms of removing bias, applying methods to risk assessments that focus on establishing facts rather than subjective scoring is also essential to better decision-making. For example, asking risk assessors a series of questions around the maintainable life of equipment, quality of maintenance records, and resiliency of the system, and using the answers to calculate a reliability score. We found that this creates a much better evidence base than asking individuals to apply a 1-5 score without a clear rationale.

This evidence base then creates a much better case to be presented to senior stakeholders. Carefully considering how risks are assessed including the impact on clinical services, the likelihood of failure, and what mitigations have already been done, creates a foundation for an argument for investment in a much better way than a fear-based approach around high-risk scores that are not underpinned by evidence.

Finally, any plan and methodology must be designed on the assumption the plan will change. New items will arise, Trust circumstances will change, and a well-thought-out strategy that accommodates the fact that things will change will lead to results far more likely than a strategy that assumes an environment like an NHS Trust will remain static.

A first step would be to combine available data, 
such as six facet surveys or risk databases, and integrate it into a sensible, quantifiable risk analysis, in accordance with NHS Risk based methodology for managing backlog.4

Once risks are quantified, taking into consideration predicted budget allocations, a deliverable multi-year programme of works is produced. This programme will focus on risk reduction first, but impact on service delivery and costs are taken into consideration as well. Projects are sequenced within available budgets, including Trusts’ priorities for each financial year. We have found this works well and this methodology helps to minimise any potential discipline bias when risk rating. Risks which translate into short-term deliverable projects are considered for year-end last minute funding allocations.

Risks do not remain static over time. Smaller risks which are not remediated on time can grow until they become a widespread problem in the hospital. Increasing maintenance or energy costs or systems failures which can close entire wards, disrupting patient care and clinical delivery, are some examples of the potential consequences. For example, a pump failure which results in increased legionella counts, with subsequent cost of legionella filters and testing, increases risk for patients and longer hospital stays.

Similarly, budgets or priorities can change year after year. For example, new financial constraints can lead to lower budgets, newly discovered risks, or need to integrate newer clinical areas, can lead to a re-prioritisation of works, which were not envisaged in the beginning.

This is why multiple iterations and scenarios can be run from the data, which can be used to present possible scenarios and risk growth to decision makers, or to ensure further funding in a clear manner. This enables estates teams to present a clear, evidence-based strategy to the Board.

Measurable improvements

This is not a theoretical exercise. Structured approaches to backlog and risk analysis have already supported measurable improvements in estate risk management. This enables Trust Boards to be presented with clearer information and a more transparent picture of the risks and their potential disruption to clinical services.

In practice, we have observed measurable reductions in risk within a single year, even with the constraints of an operational NHS environment, including working around clinical areas, procurement compliance, and delays in funding approvals. Ongoing data iterations, which incorporate new priorities, updated risks, and budget adjustments, allow for programme reviews and further risk reduction forecasts in the upcoming years.

Multiple scenario analysis supports estates teams in presenting technical data and estate risks in a way that aligns with the wider hospital strategy, improving understanding and support from decision makers.

We have seen in several cases working with NHS Trusts, the use of data-led prioritisation and planning has allowed for a greater amount of risk reduction per pound spent as well as an ability to plan much longer term.

Sustainability and Net Zero

The NHS has committed to reaching zero carbon emissions by 20405 for its directly controlled emissions (2045 for its wider supply chain), placing increasing sustainability expectations on Trust estates and capital planning.

Some Trusts have set more ambitious targets to achieve Net Zero ahead of national timelines. While sustainability plans can be developed to achieve these ambitions, in many Trusts the condition of the estate and the scale of maintenance backlog forces teams to prioritise immediate operational risks, limiting the ability to focus on sustainability targets.

Addressing backlog maintenance first does not conflict with sustainability objectives. As well as reducing risks, it can improve energy efficiency, reduce maintenance costs, and contribute to carbon reduction. As backlog projects are completed, the associated sustainability improvements can be quantified, providing a clearer understanding of the wider value of investment to board level decision makers. This is directly correlated using years of ERIC data to analyse the carbon performance of Trusts relative to the amount of backlog maintenance prevalent within an estate. Conclusively, there is a direct connection between poor maintenance condition and lower carbon performance.

Morale and wellbeing

The effect of an estate that is not fit for purpose has 
on care outcomes and staff wellbeing both for clinical and estates staff can be significant. Correlating can be difficult to confirm as processes and systems for risk reporting and management have created separation between the impact of backlog maintenance and the clinical impact. However, a 2022 report from the British Medical Association (BMA) found that 43 per cent of doctors believed poor workplace conditions were negatively affecting patient care, while 38 per cent 
rated their facilities as poor or very poor. Furthermore, 
the effect of backlog maintenance on revenue 
generation through downtime for key healthcare services is an area that needs further dedicated research and quantification. The financial implications of backlog maintenance extend far beyond repair costs. Every time an operating theatre or ward is closed due to infrastructure failures, trusts lose thousands of pounds in revenue and valuable staff time. In addition, hospital bed closures, caused by estate issues, exacerbate system-wide pressures, resulting in delays in-patient admissions and ambulance handovers.

In addition, the impact of the estate conditions on staff wellbeing and morale is increasingly recognised as moral injury which has significant detrimental effects on staff turnover. Beyond morale, operational disruptions caused by infrastructure failures — such as ward closures — result in cancelled procedures, contributing to longer waiting lists and delayed care. These disruptions ripple through the system, causing inefficiencies and increasing patient wait times.

A structured, unbiased approach

Although estates risks are well known to estates teams, day to day operational pressures, alongside fragmented and incomplete data, can make it difficult to translate known issues into deliverable estates programmes.

Multiple organisational and assurance layers, as well as limited representation of estates at board level, can dilute the urgency of risks and their potential effects on clinical areas and patient care outcomes. As a result, estate investment budgets are reduced, limiting estates teams’ ability to act, contributing to a vicious cycle of increasing backlog, rising risks, and increased operational pressures.

Despite the Government’s NHP programme announcement, a significant number of Trusts will continue to manage ageing estates and increasing backlog problems. Procurement constraints, insufficient funding, and the pressure to maintain clinical operations, often result in small scope solutions, designed to mitigate immediate risks. In the long term, these solutions increase risks and energy costs and create further strain on hospital infrastructure capabilities and team resources.

A more structured approach is required. We have found that, by analysing existing data, however incomplete, and translating it into a clear, risk-led, deliverable programme of works, this can support estates teams in presenting evidence-based investment plans to the Boards. This enables a clearer understanding of risks, their potential to disrupt clinical services, and the implications of different investment scenarios over time.

A structured, unbiased approach to backlog and risk analysis can enable Trusts to develop and deliver multi-year programmes, focused on risk reduction while balancing impacts on clinical areas — supporting sustainability objectives and improving staff wellbeing.

References

1 The Health Foundation. The NHS maintenance backlog: rising costs and falling investment. 2024

2 Serle J. Estates and facilities management in the NHS: 2026 update. Health Service Journal. 23 Apr 2026

3 Ellis C. Smaller, leaner estate: making it happen. Health Estate. 2012; 66(9):29—33

4 NHS England. A risk-based methodology for establishing and managing backlog. 2004

5 NHS England. Delivering a Net Zero National Health Service. 2020