Article Summary
Drawing on the perspective of Pradip Karanjit, Fit for the Future Director – Elective Care, Sandwell and West Birmingham Hospitals NHS Trust and The Dudley Group NHS Foundation Trust, this article explores whether the NHS's long-term sustainability challenge can be solved by building more hospitals. As the NHS shifts towards prevention, community-based care and digital delivery, Pradip argues that some of the infrastructure needed for this transformation may already exist within our towns and cities. The question for healthcare leaders is no longer how many hospitals we build, but how effectively we use the spaces that already sit at the heart of our communities.
The NHS remains one of Britain’s most important public institutions. Since its creation in 1948, it has provided care based on need rather than ability to pay, adapting repeatedly to changing public expectations, advances in medicine and shifting demographic demands. Yet the challenges facing today’s NHS are fundamentally different from those it was designed to meet.
The population is larger, older and living with more complex health needs than ever before. Long-term conditions, multimorbidity and increasing demand for ongoing care are placing sustained pressure on services across primary, community and acute settings. At the same time, workforce shortages, financial constraints and growing public expectations continue to stretch capacity across the system. Against this backdrop, it is becoming harder to argue that the traditional model of healthcare delivery can simply be expanded to meet future demand.
For years, debates about NHS infrastructure have been dominated by discussions around ageing estates, rising maintenance backlogs and the need for new hospitals. The assumption has often been that growing demand requires more physical hospital capacity. But what if that assumption is wrong?
Challenging the hospital-centred model
When discussions turn to NHS recovery, the proposed solutions are often familiar: more funding, more beds, more staff and more hospitals. Each has merit, and in many parts of the system additional capacity is undoubtedly required. Yet these interventions largely respond to the pressures experienced today rather than addressing how healthcare will need to be organised in the future.
The NHS 10-Year Health Plan signals a different direction of travel. Rather than continuing to reinforce a predominantly hospital-centred model, it sets out an ambition to deliver more care closer to people’s homes, expand the role of digital technology and place greater emphasis on prevention and earlier intervention. As Pradip describes it, the ambition should be to provide “the right care, in the right place, at the right time.”
This does not diminish the importance of acute hospitals. Hospitals will remain essential for emergency care, major surgery, intensive care, specialist treatment and the complex interventions that depend upon concentrated clinical expertise, technology and infrastructure. But they do not need to remain the default setting for every interaction with the health service.
Routine outpatient appointments, elements of diagnostics, rehabilitation, follow-up care, preventative services and the management of some long-term conditions can, where clinically appropriate, be delivered outside the acute environment. When activity that could be provided elsewhere continues to occupy constrained hospital estate, the consequence is not simply an inefficient use of space. It limits the capacity available for the patients and services that genuinely depend upon the acute setting.
The shift towards neighbourhood healthcare should therefore be understood as more than a relocation of services. It represents a different way of organising capacity across the health system, with acute hospitals able to focus more deliberately on complex and specialist care while appropriate services are brought closer to the communities they serve.
If the NHS is serious about that transition, an important question follows: where should this future care be delivered?
Learning from a transformation that has already happened
The answer may lie in another major societal shift that has already reshaped how people live, work and use their local communities. The COVID-19 pandemic accelerated changes that many organisations had previously expected to take years, if not decades. Remote working, digital collaboration and virtual services became embedded almost overnight, fundamentally altering patterns of work and the use of commercial space.
The physical consequences are now visible across many towns and cities. High streets contain growing numbers of underutilised retail units, former department stores and vacant commercial properties as organisations adapt to new patterns of demand.
Healthcare has undergone its own transformation over the same period. Patients have become more accustomed to accessing services digitally and increasingly expect care to be convenient, accessible and better integrated into their daily lives. For routine appointments, diagnostics, rehabilitation and preventative services, travelling to a large acute hospital can create unnecessary complexity where safe, high-quality alternatives could be provided closer to home. As Pradip suggests,
Healthcare delivery increasingly needs to reflect how people live, rather than requiring patients to organise their lives around the location of healthcare services
This creates an important point of convergence between the NHS’s ambition to deliver more care within communities and the growing availability of underused buildings in the places where those communities already live, work and travel.
Former retail units, department stores and commercial premises may therefore offer an opportunity, where clinically and technically appropriate, to create neighbourhood health facilities in familiar and accessible locations. Rather than starting with the assumption that new community capacity must always require new construction, healthcare leaders can consider how existing assets might be adapted to support changing models of care.
This represents a shift in thinking about healthcare infrastructure itself. The question is no longer simply where services can be housed, but how the NHS can use existing community assets to support a more distributed, accessible and sustainable model of care.
A wider opportunity for healthcare
As Pradip argues, the conversation should not begin and end with the question of where services can be relocated. It should also consider how healthcare investment can contribute to the broader health, vitality and sustainability of the communities it serves.
The potential benefits extend well beyond healthcare delivery alone. Bringing services into high streets and town centres can reduce travel for patients, improve accessibility and make care easier to reach within familiar community locations. At the same time, shifting appropriate activity away from acute hospitals can release constrained capacity for emergency, specialist and inpatient services. There is also a wider economic and community dimension. Healthcare facilities can generate regular footfall, support local businesses and contribute to regeneration in places affected by declining commercial occupancy.
Used in this way, the opportunity is not simply about making better use of vacant buildings. It is about addressing several challenges at once: improving access to care, relieving pressure on acute hospitals, supporting local economies and creating a stronger connection between healthcare services and the communities they serve.
The future sustainability of the NHS will depend on more than additional funding, workforce growth or the construction of new facilities. It will depend on whether healthcare leaders can redesign services around how people live, access care and engage with their communities.
Acute hospitals will always remain central to the NHS. But if the ambition is to deliver more preventative, integrated and community-based care, then the future of healthcare cannot be confined within hospital walls alone. As Pradip argues,
Perhaps the future of the NHS is not about building more hospitals. Perhaps it is about building healthier neighbourhoods
