Article Summary
Drawing on a conversation between FORTIS and Fiona Lennon and Cheryl Riotto of the New Hospital Programme, this article reflects on why clinical strategy matters so deeply in the planning of hospitals, and what is at risk when it is treated as an afterthought rather than a foundation.
Discussions about new hospitals often move quickly towards the physical form of the building. Attention turns to departmental layouts, room schedules, circulation routes, adjacencies and the overall configuration of clinical space. These are essential parts of hospital planning, and understandably they attract attention. They are visible, tangible and necessary to cost, test and deliver. But they should not be the starting point. Before a new hospital can be designed well, a more fundamental question has to be answered: what is this hospital being built to enable?
That question sat at the heart of a recent FORTIS conversation with Fiona Lennon and Cheryl Riotto, Deputy Clinical Directors at the New Hospital Programme (NHP). What emerged was not simply a discussion about guidance, tools or programme methodology, but a clear argument for a different way of thinking about healthcare estates. At a time when the NHS is facing sustained operational pressure, workforce constraint and rising demand, new hospitals cannot be planned as buildings alone. They must be planned as enablers of safer, more effective and more sustainable models of care.
Clinical strategy, as Fiona and Cheryl described it, should not be treated as a supporting document, produced to justify decisions already made. It must be the foundation from which those decisions flow. Without that discipline, even a major capital investment risks delivering a new building that carries forward old assumptions.
This matters because the NHS cannot afford to reproduce today’s pressures in newer surroundings. Across the estate, clinical teams are already adapting around environments that too often constrain care rather than support it. They manage inefficient routes, fragmented departments, limited flexibility and risks that have become normalised through necessity. A new hospital creates a rare opportunity to step back from the pressures of the present and ask what needs to change for the future. That opportunity is only realised when clinical intent leads from the outset.
The risk of designing without direction
Hospital design naturally gravitates towards what can be seen. Once drawings exist, they begin to carry authority. Corridors, blocks, lift cores and adjacencies can begin to feel inevitable, even when the clinical logic behind them has not been fully tested. As plans develop, decisions gain momentum. Assumptions become harder to challenge and compromises are negotiated in response to drawings rather than outcomes. For Fiona, this is exactly where things too often go wrong,
Organisations should not be designing hospitals, developing schedules of accommodation or modelling demand and capacity without first being clear about how care is intended to work
Clinical strategy, in this sense, is not something that follows design. It underpins the operating model the building must support. That distinction matters because a hospital is not simply a physical asset; it is an operating model made real. Every design choice has clinical consequences. The distance between departments can affect safety and flow. A poorly conceived lift strategy can make patient transfers more complex than they need to be and ultimately harder for the staff to deliver. Spaces that are designed without a clear understanding of the tasks that take place within them, push staff into workarounds from the moment the building opens.
Cheryl illustrated this through examples drawn from existing hospitals. Staff eating lunch in corridors because staff facilities are too distant to reach within a break. Patients moved long distances through buildings because appropriate routes do not exist. Vulnerable people transferred through spaces never designed for them. These are not minor inconveniences; they are signs that clinical need, operations and estate have drifted apart.
What makes this particularly challenging is how easily such conditions become accepted. Teams adapt, processes bend, and workarounds become part of everyday practice. As Fiona observed, many organisations have normalised working in environments that fall well short of what good care could look like. Clinical strategy plays a vital role in making those constraints visible again, so future hospitals are designed around the care the NHS needs to deliver, not simply the limitations it has learned to tolerate.
Clinical strategy as a practical discipline
A common misconception is that clinical strategy is abstract, something that sits above day-to-day reality rather than shaping it. It can be seen as a high level statement of ambition, detached from the realities of wards, theatres, diagnostics, urgent care flows and workforce pressures. Fiona and Cheryl were clear that this view fundamentally misunderstands its purpose and creates real risk when applied to hospital development. A good clinical strategy starts with practice. It asks an organisation to describe where they are now with honesty and specificity. Who is not being served well? Where are outcomes falling short? Which risks are being managed every day because the environment or model of care does not allow them to be resolved?
These are questions clinical teams understand because they live with them. Strategy brings those realities together into a shared case for change. From there, the intent becomes clearer. What needs to improve, for which patients, and in what ways? What should patients experience differently in the future? What should staff be enabled to do more safely, consistently and efficiently?
The final step is how to get there. This is where clinical strategy becomes a programme of transformation rather than a statement of ambition. It should identify the models of care, operational changes and system partnerships needed to make the vision real and should complement digital and workforce strategies.
Importantly, this is not about pretending the future can be predicted with certainty. New hospitals take years to deliver and demand, technology, workforce models and population needs will continue to evolve. The purpose of clinical strategy is not to fix answers for an opening date far in the future, but to establish a direction that can be tested, refined and carried through each stage of development. In that sense, clinical strategy becomes a decision‑making discipline rather than a static document.
Connecting strategy to design, capacity and systems
One of the greatest challenges in hospital development is traceability. Many organisations can describe their ambitions at the start of a programme, but fewer can show, years later, how those ambitions have shaped the eventual building. Cheryl reflected that previous hospital developments have exposed this weakness. Clinical strategies were present because they were required, but the link between the original ambition and the final design was not always clear. Somewhere between intention and delivery, the connection was lost.
This gap matters. If strategy cannot be traced through demand and capacity modelling, schedules of accommodation, clinical adjacencies, operational planning and business case updates, it cannot reliably shape outcomes. For senior leaders, traceability provides a way to test decisions as complexity increases. Does this design choice support the model of care we have agreed? Does it reduce a known clinical risk, or simply move it elsewhere? Are capacity assumptions grounded in realistic expectations of system change?
This also requires organisations to look beyond the hospital itself. Hospitals do not operate in isolation. Their effectiveness depends on primary care, community services, mental health provision, diagnostics, social care, ambulance services and regional networks. A clinical strategy written without the wider system risks overstating what the building alone can solve.
As models of care evolve, not all activity needs to sit within acute hospital walls. Some care may be supported through community diagnostic centres, digital pathways, outpatient transformation, virtual wards, ambulatory models or networked specialist services. But these assumptions must be evidenced, agreed and operationally credible. If a future hospital is sized on the basis that activity will be mitigated elsewhere, leaders need confidence that those mitigations are real, deliverable and owned across the system. Clinical strategy cannot remove uncertainty, but it can make assumptions visible and testable before they become embedded in the building.
Standardisation with clinical purpose
The NHP is often associated with standardisation and repeatability, and for some this can sound like a threat to local nuance. In reality, the clinical argument is more balanced. Standardisation is not about ignoring local need. It is about reducing unnecessary variation that adds cost, delay, complexity or risk without improving care. When every scheme starts from scratch, the system loses the opportunity to learn. When every room is treated as bespoke, repeatability is lost. When beds are counted differently across organisations, capacity planning becomes unreliable.
Fiona highlighted bed definitions as a simple but telling example. Overnight beds, day case beds and maternity beds are often interpreted differently, meaning organisations may assume alignment where none exists. A shared approach creates clarity and provides a common basis on which assumptions can be tested. The same applies to schedules of accommodation. At their best, they translate clinical intent into functional space, however without strong strategy behind them, they risk becoming lists of rooms rather than expressions of how care should work.
For senior leaders, the balance is critical. Standardisation should create the conditions for better clinical delivery, not constrain it. Local strategy should explain where adaptation is needed and why. Evidence should inform both.
A leadership test for the NHS
If clinical strategy is genuinely going to lead hospital design, it cannot sit with a single team or discipline. It needs ownership across the organisation and the wider system, supported by visible and sustained leadership.
That means creating the space for honest conversations about current constraints and being prepared to slow the process down rather than rushing into drawings before the clinical case is properly formed. It also means shaping strategy through engagement, listening to clinical and non‑clinical staff, patients, the public and system partners, and allowing those perspectives to influence direction rather than simply endorse decisions already made.
Crucially, strategy must remain visible throughout the programme. It should inform business cases, design assurance, public engagement, workforce planning, digital investment and operational readiness. When difficult trade‑offs arise, as they inevitably will, strategy should provide a shared reference for deciding what matters most. Without that, design risks becoming a negotiation between competing priorities rather than a clinically grounded response to patient need.
The same discipline applies to transformation. Clinical strategy is not something that belongs solely to the moment a new hospital opens. It should shape what organisations begin doing well in advance. The years leading up to a new building are not a pause in activity. They are the period in which teams can start testing new models of care, strengthening system partnerships, building workforce capability, introducing digital pathways and shifting activity where it makes sense to do so. When that opportunity is missed, the risk is clear. New infrastructure inherits old behaviours.
This is why clinical strategy matters so deeply. It connects infrastructure to outcomes; anchors design in clinical purpose and helps organisations avoid building around today’s dysfunctions. It gives clinical teams a genuine voice in shaping the environments in which they will care for patients for decades to come.
The future hospital cannot be judged by architecture alone. It must be judged by whether it helps staff deliver safer care, whether it improves patient experience and outcomes, whether it supports new models of delivery and whether it is able to adapt as needs change. That work does not start with construction. It starts much earlier, with a clear, honest and shared understanding of what the hospital is trying to do.
