Article Summary
As NHS systems face rising demand and limited capital, the question is no longer how to expand the estate, but how to use it differently. In this FORTIS conversation, Former Sandwell & West Birmingham NHS Trust CEO Richard Beeken explores why the current model no longer fits and what needs to change.
For decades, the NHS estate has been shaped by a model that felt stable, familiar and largely unquestioned. The District General Hospital became the backbone of service delivery, a physical anchor for communities and a symbol of accessible care. It made sense for the time it was built in, but the conditions that once made that model effective have changed, and the estate has not kept pace. What is becoming increasingly clear is that this is not simply about improving or upgrading what already exists, but a growing recognition that the system is still working within a framework that no longer reflects how care is delivered or what patients need today.
As Richard Beeken, Former CEO of Sandwell & West Birmingham NHS Trust and now a Leadership and Management Consultant reflects, “the NHS has been working in a paradigm that’s rather out of date,” one that struggles to respond to an ageing population, growing complexity and the rise towards more specialised care. This gap between how care operates and how the estate is structured is becoming harder to ignore. Demand continues to rise, expectations are changing, and yet much of the physical footprint of the NHS still reflects a very different version of healthcare. The question, then, is not just how to improve or modernise buildings, but whether the estate in its current form is actually supporting the system to do what it needs to do. This article draws on a FORTIS conversation with Richard Beeken, whose experience across system strategy and hospital and community service delivery offers a practical perspective on where the estate is falling behind, and what needs to change.
The Inefficiencies of the Current Model
At the centre of this sits an uncomfortable but increasingly unavoidable truth: the traditional model is no longer sufficient on its own. Care is moving, becoming more preventative more community-based and more tailored to individual need. Yet the estate has not moved with it. Much of it remains centred around acute settings, built for a model where most activity happens within the hospital. That misalignment creates pressure across the system. Hospitals continue to absorb demand that could be managed elsewhere, while community pathways are not always developed or connected enough to act as a true alternative. The result is inefficiency, but more importantly, it is a system that feels harder to navigate, both for patients trying to access care and for staff trying to deliver it.
There is a growing recognition that this is not about fine-tuning the existing model. It is about questioning whether it still works at all. That shift in thinking leads to a more fundamental challenge. It requires a change in how estate decisions are made in the first place. Too often, buildings are treated as the starting point, with services shaped around them. In practice, this means working within the constraints of what already exists, rather than designing around what care actually requires. Richard was clear on this point, “Buildings are just buildings, it’s the services and the people delivering those services… that are being redesigned all the time, and the buildings are a byproduct of service design.”
That distinction changes the conversation. It shifts the focus away from infrastructure and towards outcomes. When estate strategy starts with clinical need, patient flow and workforce capacity, the spaces that follow are far more likely to support the system effectively. When it starts with existing assets or available funding, it often ends up reinforcing the very issues it is trying to solve. This is where many organisations find themselves stuck. Estate strategies can be detailed, technical and well-intentioned, but still fail to drive real change. They are often developed separately from clinical strategy, and more focused on describing the current estate than defining what is needed in the future. Without that connection, it becomes difficult for the estate to do what it should do, which is to enable a different way of delivering care.
The constraint that forces change
If the model is under strain, the conditions it now operates within are just as important to understand. Capital is limited, and the ability to rely on large-scale funding to reshape the estate is becoming increasingly uncertain, which is starting to shift the conversation in a more fundamental way. Rather than asking what can be built next, organisations are having to look more closely at what they already have, how it is being used, and whether it is actually supporting the way care needs to be delivered. That shift is not always comfortable, but it is where much of the real opportunity now sits.
In this context, what Richard described as creativity becomes less about new ideas and more about better judgement. It is about being willing to take a clear view on what is working and what is not, and then acting on it, whether that means releasing estate that no longer serves a purpose, using space more intelligently across services, or thinking more carefully about how facilities can support both clinical care and the communities around them. It also brings into focus a question the system has returned to repeatedly but has struggled to move forward in practice, which is how far organisations are prepared to work beyond their own boundaries. The idea of a shared public estate has been widely discussed, and the logic behind it is clear, yet progress has been limited. The barriers are not only financial. They sit in how organisations are structured, how decisions are made, and how accountability is held, which makes change slower and often more difficult than it needs to be. Even so, as pressure on capital continues, those barriers become harder to defend, and the case for using public estate more collectively becomes less theoretical and more necessary.
A Different Approach in Practice
During the discussion, the development of the Midland Metropolitan University Hospital came up as a useful example of what this looks like when it is applied in practice. The starting point was not the building itself, but a different set of assumptions about how care should be delivered. Rather than replicating a traditional model, the approach focused on changing how the system worked around the hospital. This included a deliberate reduction in bed numbers, supported by a significant expansion of community-based alternatives. New pathways were put in place to provide ambulance services and GPs options beyond hospital admission, while elective and emergency care were separated to protect planned activity and reduce disruption.
What followed was not simply a new hospital, but a different way of using capacity across the system. As Richard reflected, without these changes, “we would have ended up with a worse outcome” with pressure carrying straight through into a new building rather than being addressed. That is what makes this example important. It shows that estate on its own does not solve the problem. The value of the building depends entirely on the model of care around it, and without that alignment, even the most modern facility risks reproducing the same pressures in a different form.
The Human Factor in Transformation
Even the most carefully thought through strategies can come unstuck if they overlook one of the most difficult parts of change, which is people. In healthcare, resistance is not unusual, it is part of the process. Staff are often being asked to work in new ways, sometimes in environments that feel unfamiliar, while communities can have a strong sense of attachment to existing services and buildings. Alongside this, political pressure can quickly build, shaping decisions and slowing progress in ways that are not always easy to manage.
Richard is clear about the scale of this challenge, warning against underestimating “the resistance of your staff to working in a new care model and working in a building that operates in a very different way.” What this highlights is that transformation is not just about having the right plan. It is about how that plan is understood and carried through in practice. Leadership plays a central role here, not only in setting direction, but in making the case for change in a way that feels real and credible to the people affected by it. Formal strategies and business cases have their place, but they are rarely enough on their own. What tends to make the difference is whether people can see how the changes will improve care, how it will affect their day-to-day work, and where they fit within that future. Without that connection, even well-designed plans can struggle to take hold.
What Should Not Change
In a system that is changing as much as this, it helps to be clear about what is not changing. Models of care will continue to evolve and technology will move forward, but some expectations remain constant. Patients still want to be able to access care when they need it, they want to be treated with dignity, and they want to feel safe throughout their experience. Those expectations are simple, but they are also consistent, and they have not shifted in the same way as the system around them. That matters because it gives a reference point. When there is uncertainty about what the future should look like, these fundamentals offer a way of testing whether decisions are moving in the right direction.
If estate strategy is shaped with those outcomes in mind, it becomes easier to navigate the complexity that comes with change. Decisions about where care is delivered, how spaces are designed, and how services connect to each other can all be considered against a clear question, which is whether they are making it easier for patients to access care, improving their experience and supporting safer outcomes. That does not remove the difficulty of those decisions, but it does give them a clearer sense of purpose.
What comes next for the NHS estate
The direction of travel is becoming clearer, even if the detail is still evolving. The NHS estate is likely to become less reliant on large, general hospital sites and more focused on a mix of specialised facilities, community-based services and environments that support more flexible ways of delivering care. That does not mean hospitals disappear, but it does change the role they play within the wider system. What is less clear is how quickly that shift can happen. The pressures are there, both in terms of demand and the growing recognition that the current model is difficult to sustain but turning that into meaningful change is not simple. This is where the real challenge now sits.
There is already a broad understanding of what needs to happen. The challenge is not a lack of ideas, but how those ideas are translated into decisions. As the discussion with Richard Beeken made clear, the organisations that make progress are not those with the most ambitious estate plans, but those that are able to align how they think about demand, workforce and estate as part of the same problem. That requires a different starting point. Estate cannot be planned in isolation, it needs to follow a clear view of how care is going to be delivered, how demand is expected to change, and how the workforce will operate within that model. Without that alignment, even well-funded projects risk reinforcing the same pressures in a different form.
This is where many systems continue to struggle. Demand modelling, workforce planning and estate strategy are often developed separately, which makes it difficult to arrive at decisions that genuinely reshape how care is delivered. Where those elements are brought together, the estate begins to act as an enabler rather than a constraint. In that sense, the question is no longer whether the NHS estate needs to evolve. It is whether organisations are prepared to make the decisions required to align it with the care they are trying to deliver.
