The New Hospital Programme (NHP) continues to shape the conversation around healthcare construction in England. Following the programme reset, Wave 0 schemes are now on site, with a longer-term pipeline for the remaining projects.
But it is only part of the picture. Many NHS trusts are still delivering care from ageing estates, with a maintenance backlog that is both significant and growing. The Estates Return Information Collection (ERIC) reported total backlog maintenance of £15.9bn, including £3.5bn of high-risk issues that could lead to major disruption or even catastrophic failure of services if left unresolved.
For NHS leaders, this creates a difficult balancing act. The sector needs major capital transformation where buildings are no longer fit for purpose, while also dealing with the immediate operational reality of keeping facilities safe, compliant and resilient. In practice, progress depends on doing both well.
Gleeds’ work across major hospital programmes and a large volume of small and medium-scale healthcare schemes gives us a clear view of what helps trusts strike that balance. Often, it is the smaller, well-planned interventions that deliver the fastest benefits and create the conditions for larger change to follow.
Beyond the big build
Major capital programmes can transform clinical environments. They also take time, require complex enabling strategies and carry operational risk if the surrounding estate is not ready.
Targeted programmes of smaller schemes can deliver quicker, more flexible improvements across a trust’s portfolio. Refurbishments, compliance works, infrastructure upgrades, strategic extensions, and plant replacement can be planned and phased to reduce disruption, improve patient and staff experience, and address known safety risks. Over time, the cumulative impact can be transformational.
These programmes can also create the “headroom” trusts need for future redevelopment, including decant space, temporary capacity, and reconfigured flows that reduce pressure on constrained departments. Even where a major new hospital is planned, delivery often depends on enabling works being brought forward and integrated with the day-to-day operational demands of the estate.
Tackling the backlog with better data
A data-led approach is the only realistic way to regain control of backlog maintenance. Asset condition surveys, lifecycle modelling and clear risk classification allow trusts to move from reactive repairs towards planned interventions that protect clinical continuity and improve value over the life of the estate.
This also means looking hard at the “tail” of the estate. Underutilised, poorly performing or poorly located assets can become liabilities. Where estates rationalisation is the right option, decisions need to be grounded in evidence, service strategy and operational impact, not just short-term cost.
Digital capability is increasingly important. Tools such as the NHS Estates & Facilities Digital Maturity Assessment can help establish a baseline of digital maturity and data quality, and provide a practical route-map for improvement. Better data supports better prioritisation, stronger business cases, and more credible multi-year capital plans.
Keeping net zero embedded in everyday decisions
The NHS has set some of the most ambitious net zero targets of any health system. For many organisations, legacy estates make this hard. Poor fabric performance, outdated plant and ageing controls can lock in high energy consumption and create avoidable operational cost.
Net zero progress is most achievable when it is built into day-to-day maintenance and renewal decisions, rather than treated as a separate agenda. In practice, trusts are taking a mixed approach: quick-win efficiency measures such as LED lighting and controls, on-site generation such as photovoltaics, and targeted changes to heat sources including air and ground source heat pumps where the business case and site constraints allow. For much of the legacy estate, the challenge is sequencing these interventions in a way that is deliverable, affordable and minimally disruptive to clinical services.
A more resilient estate needs a balanced approach
The NHS estate will not become future-ready through new hospitals alone. The bigger opportunity lies in combining the long-term benefits of major capital projects with the pace and adaptability of smaller interventions, delivered as coordinated programmes and aligned to service change.
That alignment matters more than ever as the system shifts care closer to home. The government’s Fit for the Future: 10 Year Health Plan for England sets out that direction of travel. The Neighbourhood Health Centres confirmed at Autumn Budget 2025 reinforce the shift, and will place new demands on how existing estate is configured, maintained and invested in.
Funding remains a constraint, and the delivery challenge is real. Trusts can still make meaningful progress by grounding decisions in robust asset data, prioritising risk, packaging works to be deliverable, and ensuring every intervention improves resilience and reduces carbon wherever possible.
With deep experience across the healthcare sector, Gleeds is well placed to support NHS organisations across multiple care settings, helping them to prioritise investment, build deliverable programmes and deliver change with operational realities front of mind.
