Article Summary
Ageing estates and constrained capital are often seen as operational pressures for NHS Trusts. Drawing on insights from Matthew Custance, Infrastructure and Healthcare Sector Adviser at Barrum River Advisory, this article explores how estate challenges can instead become a catalyst for strategic transformation.
Across the NHS, many leaders are balancing two uncomfortable realities. The first is that significant parts of the NHS estate are ageing, inefficient and increasingly expensive to maintain. The second is that a full new hospital build is, for most organisations, unlikely in the near future. Yet at the same time, the strategic direction of travel is clear: more care delivered closer to home, greater use of digital and a stronger emphasis on prevention. The pressure on the estate is not separate from these shifts – it is directly connected to them.
Drawing on the insights of Matthew Custance, Infrastructure and Healthcare Sector Advisor at Burrum River Advisory, this article explores how estate pressure can be reframed not simply as a maintenance challenge, but as a strategic opportunity to redefine the role of the hospital itself. As Custance reflects, “As an NHS CEO, you are responsible for everything, but you need approvals for anything.” That tension of accountability without full control over capital is familiar to many leaders. Yet it also raises a more fundamental question. If a wholesale rebuild is unlikely, how can organisations reshape what they already have? Rather than treating backlog and capital constraint as purely operational problems, Custance argues there is an opportunity to use them as a catalyst for something more deliberate: reshaping the role and footprint of the acute hospital.
Clarifying What the Hospital is For
Acute hospital space is among the most expensive assets in the public estate. It carries the highest infrastructure costs, the most complex compliance requirements and the greatest operational intensity. That alone should prompt a fundamental question for NHS leaders: what activity genuinely needs to sit there?
Over time, many hospitals have accumulated layers of function. Outpatient clinics, day-case surgery, discharge beds, corporate offices and education facilities often sit alongside emergency care and critical services. Much of this has evolved incrementally, shaped by operational convenience rather than long-term strategy. For Custance, this is where strategic clarity begins. He describes the need to “sharpen the purpose of the hospital.” In practical terms, that means recognising that the acute site should primarily serve high-risk, high-acuity, time-critical care – services that rely on immediate access to theatres, critical care, complex diagnostics and specialist teams. Clear examples of this are emergency medicine, intensive care, interventional procedures and maternity service, these are services that genuinely require the infrastructure and adjacency the acute estate provides. Once that clarity is established, it becomes easier to ask a second, more strategic question: what does not need to be there?
Designing a Distributed Model Intentionally
Many services traditionally delivered on the acute site do not depend on adjacency to critical care. Outpatients, much elective activity, step-down capacity and corporate functions are often there because that is where space historically existed. Custance is clear that this is not about reducing services or transferring responsibility elsewhere. Instead, it is about deliberate redistribution. In his words, it means moving activity “by design, not by default.”
Relocating appropriate activity into community or town-centre settings is not about diminishing the role of the acute Trust. On the contrary, it can strengthen it. Trust-led community hubs can improve access, reduce pressure on constrained estate and support elective recovery, while maintaining clinical governance and operational control. This approach also aligns with broader system ambitions. Delivering care closer to transport links, high streets or residential areas can make appointments easier to integrate into daily life, particularly for working-age patients and carers. At the same time, it creates headroom on the acute site for activity that genuinely depends upon it. As Custance suggests, if the hospital is for high-acuity, high-risk care, then everything else should be actively tested against that principle.
The Digital and Operational Glue
Historically, hospitals concentrated services in one location so that people, equipment and information could move quickly between them. A more dispersed footprint requires that connectivity to be rebuilt in different ways. Custance describes digital and logistics infrastructure as the “glue” that holds a distributed model together. If activity moves beyond the traditional site boundary, organisations must deliberately design the systems that allow communication, coordination and flow to work seamlessly. A shared clinical record across sites, consistent approaches to virtual consultation, coordinated scheduling and effective logistics systems are not optional extras; they are the operating backbone of a distributed model. When digital investment underpins a visibly different way of working rather than simply digitising legacy processes, its strategic value becomes clearer. It enables flexibility, resilience and scale in ways that estate alone cannot.
Moving from Reactive Maintenance to Phased Transformation
Reshaping an estate is rarely achieved in a single capital event. For most Trusts, it will be an incremental, multi-year transition. That demands a disciplined plan which integrates capital investment, backlog reduction and lifecycle management. The first step is often a frank assessment of condition and utilisation. Which buildings are genuinely fit for long-term use? Which can be economically upgraded? And which represent disproportionate risk or cost? These decisions are uncomfortable, but they are necessary if scarce capital is to be deployed effectively.
Sequencing then becomes critical. Investment should increasingly be focused on buildings that align with the future role of the hospital, while active plans are developed to repurpose or dispose of vacated estate. Without that discipline, double-running costs and fragmented footprints can quickly erode the benefits of change. As Custance argues, this is not simply about managing estate better; it is about aligning estates, operating model and financial strategy in a coherent way.
Planning for Change, Not Certainty
One of the enduring challenges in estate strategy is the temptation to design around a fixed view of clinical practice. Yet the pace of change in medicine makes that approach increasingly unrealistic. Over recent decades, specialties have shifted from open surgery to minimally invasive approaches, inpatient stays have shortened dramatically, and technology has redefined what can be done safely outside a traditional ward setting. A resilient estate is therefore one designed for adaptability. Flexible space, modular approaches and infrastructure that can accommodate evolving service models are more valuable than highly specialised facilities built around today’s assumptions. In this sense, the objective is not to define what care will look like in 30 or 50 years, but to ensure that spaces can flex as models of care change.
A Strategic Choice
Trusts facing significant backlog pressures effectively have a strategic choice. As Custance argues,
One route is to continue patching and maintaining a broad and ageing footprint, managing risk year by year. The other is to use estate pressure as a catalyst to reshape what the hospital is and how care is delivered
The latter is undoubtedly more complex. It requires sustained leadership, stakeholder engagement and careful phasing. But it also offers the possibility of aligning estate, operating model and national policy direction in a coherent way. For many organisations, a full rebuild may remain beyond reach. However, a deliberate redefinition of the acute core, supported by distributed community provision and strong digital infrastructure, is not. In that sense, constraint can become a form of clarity. By sharpening the purpose of the hospital and investing accordingly, Trusts can move from reactive maintenance to strategic renewal -improving estate quality while delivering care in ways that are more accessible, resilient and future-ready.
