This article outlines the current state of the NHS estate, with the cost and severity of backlog maintenance in NHS buildings still rising, both staff and patients being affected.

In September 2019, the Government announced plans for 40 new hospitals, these plans have been accelerated as part of the Covid-19 recovery strategy.

Issues Facing the Healthcare Estate

Although plans for tackling the backlog are in place and funding has been promised, the estate has many issues to tackle.

According to the Kings Fund [1]:

  • In 2018/19 the total cost of tackling the backlog of maintenance issues in NHS trusts rose by 8.4% to 6.5 billion.
  • Of this, over half, £3.4 billion, was for issues that present a high or significant risk to patients and staff.
  • Facilities and equipment are so outdated that they no longer comply with statutory safety standards. This has left the NHS with a mix of world-class, state-of-the-art facilities and Victorian hospitals that are no longer fit for purpose.

David Williams, Head of Policy and Strategy at NHS Providers showed us what the estate is dealing with right now, and what they are faced with tackling over the next 9 months [2]:


  • New Secretary of State
  • Hot Urgent & Emergency Care
  • Full pelt backlog recovery
  • Rapidly increasing demand meets restricted capacity
  • Staff recovery and wellbeing
  • COVID-19 Delta variant spread
  • COVID-19 vaccinations

Next 9 months:

  • New NHS England CEO
  • H2 money negotiation
  • Multi-year backlog recovery plan
  • Bill and setting up ICSs as new statutory organisations
  • Getting back to fixed budgets
  • Spending review prioritisation
  • Difficult winter

The Strategy of NHS Providers in Rebuilding the Estate

David explained the backlog recovery plan that will dominate strategy for the next few years. The whole of the NHS is targeting recovery now. It is emphasised that the Covid-19 pandemic has underlined the need to set in place an effective plan to rebuild the estate.

The recovery plan must take account of different factors:

  • Problem size – bounce back impact
  • Speed of recovery e.g. lessons from accelerators
  • Money – how much will recovery cost
  • Workforce as biggest rate limiting factor
  • Innovation vs “usual approach”

Upon careful planning around these factors, a plan shaped by a systems working approach will be installed. This involves: bringing health and care together to improve outcomes for patients, collaboration, not a competition between departments in the Estate, reinforcing the collaboration that came into effect during Covid-19 and a focus on prevention as well as magnifying the problem of health inequalities.

Additionally, there is a policy shift underway. Integrated Care Systems (ICSs) are set to replace Clinical Commissioning Groups (CCGs). These ICSs will replace CCGs as the main commissioning body for the estate. This brings a need to focus on accountability and governance during this transition.

[2] The presence of Integrated Care Systems across England

Effective Building of the Estate in the Face of Covid-19

James Goulden, Principal Lease Events Manager, NHS Property Services uses the actions taken during the pandemic as an example of an effective strategy that optimised the NHS estate [3]:

  • Recommissioned space for 1,700+ beds
  • Completed 8,000+ deep cleans
  • Supporting 250+ vaccination sites
  • Creating a range of estate guidance

They highlight how the actions that were taken at this time are a great example of how people, property, and technology can come together to overcome hurdles. It shows the resilience and agility of the people involved in this rebuilding.

Optimisation of the Estate Beyond Covid-19

James outlined the projects NHS Property Services is undertaking to enable improved health and social care, by helping the NHS get the most from its estate while driving better outcomes for patients and clinicians.

  • Refurbishment and new building projects to deliver improved places, by understanding occupancy and utilisation and identifying opportunities for investment and transformation
  • Accommodating social prescribing initiatives by collaborating across organisations, locality planning and initiating new ways of working.

The 2020/21 pilot programme delivered 110 projects, which have expanded to 300 this year and will support over 4 million patients.

An example of a successful NHS Property Services project is the recommissioning of Clacton Community Hospital in Essex. 50 additional palliative care beds and 15 on-bed residential units for staff were provided by reconfiguring vacant space in the hospital.

[3] Clacton Community Hospital

Key Recommendations

Collaboration is key to creating the most effective NHS estate, sharing and maintaining good data across the NHS and aligning commissioning with estate strategies, can unlock the potential of proactive estate management. A collaborative relationship between those who commission space, those who manage space, those funding the space and those occupying the space is essential when starting a new project.

David highlighted the importance of recognising opportunities, risks and mitigations when working to rebuild the estate.

  • Notice the opportunity to speed up integration and collaboration, with a focus on population health
  • Notice the risks: Prescriptive, top-down; centralising; additional bureaucratic tier
  • Notice the need to take accountability for the population and its members as well as, providing into culture and leadership

[1] The Kings Trust, 2019. The deteriorating state of the NHS estate

[2] Williams, David, 2021. Head of Policy and Strategy at NHS Providers

[3] Goulden, James. 2021. Principal Lease Events Manager, NHS Property Services

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Considering the Governments pledge to build 40 new hospitals by 2030, this article outlines the challenges that the NHS Estate currently face. It demonstrates strategies that are in place to help clear the backlog of issues and to improve the services of the estate.

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