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Strategy, Insights

The NHS needs a phased, clinically-led, holistic approach to infrastructure development

With ‘big bang’ infrastructure projects on the rise across NHS estates, our strategy team shares their insights into how to avoid common pitfalls and their tried and tested approach for these programmes.

In a 2022 NHS Confederation survey of 182 health leaders, 90% warned that rundown estates and insufficient capital funding are hindering their ability to tackle growing waiting lists and deliver patient care safely.

As a result, NHS Trusts are understandably looking to dramatically transform their estates whilst minimising the upfront costs associated with strategic development and planning. The result is a proliferation of ‘big bang’ infrastructure projects focused on the addition of shiny new buildings to the Trusts’ estates. This approach has likely been encouraged by the terms of reference of the New Hospital Programme (NHP), which aims to develop ‘48 new hospitals.’

Our strategy team has supported the development of infrastructure programmes of a different kind. These programmes address the three most common pitfalls of ‘big bang’ infrastructure projects by being phased, clinically-led, and holistic.

The NHS needs a phased, clinically-led, holistic approach to infrastructure development

NHS estates are in disrepair 

The latest NHS building and equipment figures tell a worrying story for the state of our healthcare facilities. As Figure 1 shows, the cost of tackling the NHS’s estates maintenance backlog has risen for the eighth consecutive year, from £4bn in 2013/14 to £10.2bn in 2021/22.  The cost of the high-risk maintenance backlog – meaning estates issues which pose a high risk to the safety of patients and/or staff – has more than quadrupled in this time.  

Figure 1: The cost and severity of maintenance issues with NHS buildings and equipment is still growing 

There has been a marked increase in capital investment by the NHS in recent years, with spending expected to reach £11.3bn by 2024/25, particularly due to an influx of £3.7bn as part of the NHP. However, the funding environment for capital projects remains: 


‘Big bang’ infrastructure projects 

The ‘big bang’ approach has a number of benefits, not least achieving additional capacity, reducing maintenance backlog, and creating modern state-of-the-art infrastructure.  

Still, we have found that the potential of ‘big bang’ projects can be limited by three potential pitfalls.  

1. Not being flexible to changing funding environments 

Funding arrangements in the NHS are fluid. Requiring one gigantic upfront investment, delivery of ‘big bang’ projects can be jeopardised if they cannot secure all the funding they require or if funding is delayed. 

2. Not engaging with the clinical strategy and vision

NHS Trusts' estates exist to enable the delivery of their clinical strategy. ‘Big bang’ projects require large capital investment, which risks their design being capital-driven rather than being clinically-focused on the changes systems want to make to their health and care. 

3. Not considering interdependent projects and policies

The construction of a new hospital building is a huge undertaking – focusing attention on a single organisation or subset of in-hospital clinical services. Therefore, the health-system can miss opportunities to reconfigure care, realise digital and operational improvements, and leverage existing infrastructure. 


An alternative approach: designing phased, clinically-led and holistic infrastructure programmes 

So how can we guard against ‘big bang’ projects’ three pitfalls? At The PSC, we have supported the development of infrastructure programmes of a different kind – addressing the three pitfalls by being phased, clinically-led, and holistic. 

1. A phased programme, increasing project flexibility 

A phased programme allows plans to evolve over time according to changes in funding possibilities, strategic priorities, and models of care. This enables immediate infrastructure priorities to be delivered at pace whilst minimising the risks of delay and overspend associated with larger infrastructure projects.  

The phased approach also means that construction can be taken forward through multiple, smaller projects. This provides Trusts greater flexibility in procuring construction - a crucial advantage in a market with unprecedented pressure on capacity. The approach is also less risky for construction companies and more feasible for the local construction supply chain.

2. A clinically-led programme, connected to a clinical strategy and vision 

The best infrastructure planning stems from a clear clinical strategy, with every decision being made with clinical objectives in mind. Infrastructure projects should build on clinical objectives, align to existing work on clinical vision, and link to transformation priorities. This requires efficient but meaningful involvement of frontline clinical staff in design to ensure the end product meets the needs of both staff and patients.  

3. A holistic programme, that considers interdependent projects and policies 

The delivery of health and care is constantly changing, meaning planners should design estates that are joined up with their other strategic initiatives. This means considering: 

  • What care is delivered – What portfolio of services should the Trust offer to meet future population need? How will demand increase or decrease in different areas? 
  • How care is delivered – How can estates support the use of new and emerging technologies to improve patient experience and outcomes? How can estates improve patient flow and operational efficiency? 
  • Where care is delivered – What services must be provided at this site and what could be better delivered elsewhere or by system partners? What are the key physical adjacencies and clinical interdependencies to consider?  


Delivering phased, clinically-led, and holistic infrastructure programmes 

The PSC has successfully undertaken this phased, clinically-led, and holistic approach to infrastructure planning with several NHS clients, including participants in the NHP. We are now excited to be offering our support to NHS Trusts across the country, using our expertise in clinical engagement, healthcare strategy and systems thinking to support the development of fit-for-future estates. If you would like to discuss this or anything else in this article, please get in touch with or


Authors: Dave Chappell and Josh Myers, The PSC Strategy Team 

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