The Hidden Cost of Healthcare Design: What Happens After Handover 

Where the gap begins

In the compressed timelines and budget pressures of major healthcare projects, many decisions feel small. A clearance reduced here, a specification altered there, a room resized to accommodate another clinical priority. But in operational terms, these minor adjustments can ripple outward for decades. As Saunders puts it,

A minor tweak at the design stage can have a disproportionate impact on the running of the facility for 30+years

The financial implications of this are well understood, even if they are not always acted upon. While construction and maintenance costs tend to balance out over the lifecycle of a healthcare asset, the total cost of operating a hospital over its lifetime is estimated at between 12 and 20 times its original construction cost. The systems, spaces and assets chosen at design stage dictate how people move, clean, fix, replace and respond for decades.

In that context, operational effectiveness is not a secondary concern or a ‘nice to have’; it is the dominant cost driver, and it is largely predetermined long before the building opens its doors.

The industry knowns the problem, so why does it persist?

This disconnect has not gone unnoticed. Over the past decade, the industry has introduced a series of frameworks explicitly designed to bring operational thinking into the design process. Government Soft Landings, first introduced in 2016, sought to “align the interests of those who design and build with those who use and maintain” by embedding whole‑life evaluation across all RIBA stages.

The introduction of the GSL Champion was intended to give end users and operational teams a clear voice at the design table, supported by Plain Language Questions that cut through technical complexity and return the focus to practical outcomes.

Alongside this, standards such as BS 8536, the growing emphasis on Post Occupancy Evaluation, the Procurement Act’s requirement for whole‑life costing, and the guidance contained within HTMs and HBNs all reinforce the same principle: buildings should be designed not just to be compliant and attractive, but to be operable, maintainable and efficient over their full lifecycle. On paper, the industry now has the tools it needs. And yet, the same operational problems continue to surface.

What operational reality looks like after handover

With more than twenty years working in healthcare FM, Saunders has repeatedly encountered the same issues as buildings move from handover into live operation. From his perspective, many of the operational challenges that later feel unavoidable can be traced directly back to design decisions that were made early, often with the best of intentions, but without full visibility of their long‑term implications. These are not abstract concerns, but practical realities he has seen play out time and again.

Hospitals, Saunders observes, frequently enter into operation with plant that cannot be properly accessed, assets that were selected for upfront cost rather than longevity, and systems that technically comply at handover but generate significant burden thereafter. What works on paper, and what passes compliance checks at completion, does not always work in practice once the building is under daily pressure.

Seemingly small choices made during design can quietly drive inefficiency for years. Fire alarm systems that save marginal capital cost can create repeated disruption every time they activate. Lifts that were never truly designed around patient movement quietly double porter requirements without any explicit decision ever being made to do so. Back‑of‑house spaces such as cleaning cupboards and waste holds are frequently pared back to accommodate clinical aspiration, only for the operational impact to reappear later as increased labour, cluttered corridors and avoidable service disruption.

As Saunder points out, these outcomes are rarely the result of negligence or poor intent. More often they are the product of design decisions made without full exposure to their operational consequences – decisions that make sense within the narrow context in which they are made but unravel when tested against thirty years of everyday use. This is where the disconnect between design intent and operational reality becomes most costly, not in dramatic failures, but in the accumulation of small inefficiencies that no one ever set out to create.

Why the same problems keep repeating

When Saunders reflects on why these issues continue to surface, he is clear that they are not the result of isolated mistakes, but of a small number of structural pressures that repeatedly shape design decisions in the same way.

The first, and perhaps most visible, is space. In almost every hospital project, space is finite and highly contested. Clinical teams will always push for more beds, more theatres and more clinics, and rightly so. The consequence, however, is that the spaces seen as less critical during design are the ones most likely to be eroded. Cleaning cupboards, waste holds, storage areas, kitchens and logistics spaces rarely disappear entirely, but when they are reduced, their cost does not go with them. Instead, it re-emerges later through increased staffing requirements, inefficiency and operational risk.

Cost structures reinforce this pattern. As Saunders points out, the individual responsible for approving the capital budget is often not accountable for the ongoing maintenance and operational spend. These costs sit in different financial silos, governed by different incentives and timescales. The result is a system that quietly rewards short‑term capital savings, even when those savings lead to higher costs over the life of the asset. Decisions that appear prudent at the point of approval can prove disproportionately expensive once the building is in use, despite a widespread understanding, at least in principle of whole‑life value.

FM engagement is another recurring weakness. In Saunders’ experience, FM teams are frequently brought into projects too late to meaningfully influence design outcomes. Even when they are involved earlier, they may lack the authority or the detailed understanding of design development required to challenge emerging decisions. By contrast, he notes that PFI schemes -whatever their other limitations – have often proved more effective at embedding FM and service delivery thinking from the outset, precisely because the organisations responsible for operating the building were structurally involved in shaping it.

Underlying all of this is the unavoidable time lag between design and operation. Hospitals can take many years to progress from concept to occupation. During that period, technology evolves, regulations change and expectations of efficiency, productivity and staff experience continue to rise. Designing a hospital today that will support effective FM delivery six or seven years in the future is, as Saunders’ acknowledges, a significant challenge. But difficulty, he argues, should not be confused with inevitability. The existence of uncertainty does not remove the responsibility to get the fundamentals right.

Focusing on the fundamentals that don’t change

Saunders is clear that acknowledging the gap between design and operation does not mean accepting it. While the time lag between design and occupancy is real and the pace of technological, regulatory and operational change undeniable, there are still core principles that can and should be addressed every time. Rather than trying to perfectly predict how a hospital will be operated six or seven years into the future, he argues that the focus needs to shift to what remains fundamentally constant.

If we accept that not everything can be forecast, the more productive question becomes: what does not change? In Saunders’ view, the answer lies in a small number of operational fundamentals that apply regardless of technology or methodology.

Access is non‑negotiable. Can the people responsible for maintaining the building physically reach what they need to reach, using the equipment they need, without disrupting clinical services?

Sizing is equally critical. Are non‑clinical spaces designed around real, lived operational requirements, rather than whatever space happens to remain once clinical ambition has been satisfied?

And specification still matters deeply. Are assets and systems selected on the basis of whole‑life cost, maintainability and resilience, rather than capital price alone or compliance at handover?

These are not sophisticated or novel questions. They do not rely on cutting‑edge technology or complex modelling. They rest on experience. As Saunders’ puts it, “they require someone in the room who knows what it’s like to run a hospital and the challenges they face on a day to day basis.”

That insight must be present early enough to influence outcomes and backed by the authority and confidence required to challenge decisions as they are being formed, not once they are already fixed.