CAPITAL PROGRAMMES
Capital programmes need whole system change
Samuel Rose, director, health strategy, IMPOWER Consulting, and Dr Nicole Samuel, commercial director for the National Centre for Child Health Technology at Sheffield Children’s NHS Foundation Trust, present findings from a qualitative research programme examining how clinical and digital transformation can be embedded within large-scale healthcare capital programmes. Drawing on case study reviews, interviews with programme leaders and CEOs, and analysis of hospital openings, their research reveals a persistent and dangerous gap between the transformational ambitions built into business cases and the operational reality that new hospitals face at opening.
When a new hospital opens its doors, the assumption is that things will get better – for patients, for staff, and for the health system. New facilities are conceived to solve longstanding problems: ageing estates, fragmented care pathways, rising demand, and a workforce stretched to its limits. Yet the uncomfortable truth, borne out by hard evidence from recent major hospital openings, is that a new building can make things worse before they get better – sometimes significantly so – if the transformation required to make it work is not planned, funded, and delivered in parallel with the bricks and mortar. This is the central finding of research conducted by IMPOWER Consulting, working in collaboration with UCL’s Bartlett School of Sustainable Infrastructure. The study examined three recent major hospital openings – the Royal Adelaide Hospital in Australia, the Royal Liverpool University Hospital, and the Midland Metropolitan University Hospital in the West Midlands – alongside interviews with approximately eight New Hospital Programme (NHP) programme leaders and a survey of programme directors on transformation readiness. What the research reveals is not just an observation about past projects, but an urgent warning for every capital programme currently under development in the NHS.
Understanding the transformation gap At the heart of the problem is what the research terms the ‘transformation gap’: the distance between what a new build is designed to achieve and what people, processes, and technology are actually ready to deliver on opening day. This gap is not simply a matter of programme management. It is structural. It is baked into the economics of hospital building itself. The business cases underpinning NHP schemes are built on ambitious assumptions. They routinely project a 12 per cent reduction in average length of stay and a 1.8 per cent reduction in acute bed demand – reductions to be achieved through redesigned care pathways, digital integration, virtual wards, and a significant shift of services into community settings. These are not aspirational footnotes; they are the operational and financial foundations on which the capital case for investment rests. Without them, the numbers simply do not add up. The financial stakes are considerable and are often underestimated at programme level. When a new hospital opens, the Trust faces a significant and immediate increase in recurrent revenue costs and productive targets: potential additional workforce expenditure driven by single-room layouts and changed staffing ratios; higher assumptions on activity throughput; higher facilities management costs
from larger floor areas; greater digital operating costs; and depreciation on the new asset and Public Dividend Capital (PDC) charges paid to DHSC on the value of public capital invested. In the current NHS financial environment, where existing budgets are already under extraordinary pressure, these new costs can represent a significant financial challenge for individual Trusts and their Integrated Care Boards – on top of very challenging financial improvement plans. The research found that the responsibility for meeting
these costs falls squarely on local organisations – Trusts and ICBs – not on the national NHP programme, whose primary focus remains on managing capital expenditure and build programme timeline. This creates a critical and largely locally owned risk.
When assumptions outpace readiness: lessons from recent openings The case studies examined in the research provide a sobering illustration of what happens when the transformation gap is left unaddressed.
n Royal Adelaide Hospital, Australia Opened in 2017 as a flagship public-private partnership hospital in South Australia, the Royal Adelaide was designed around an integrated model of care, seamlessly connecting infrastructure, IT systems, and workforce. In practice, the integration failed to materialise at pace. Local media reported on chronic emergency department overcrowding, major failures of its electronic patient
Royal Adelaide Hospital, Australia.
August 2026 Health Estate Journal 57
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