CAPITAL PROGRAMMES
Fig 2: Four-stage framework for embedding
transformation within capital programmes.
3. Deliver at scale, in parallel with construction. Whole- scale transformation programmes must run alongside capital construction, with dedicated leadership and dedicated resource. The research is clear that Trusts cannot transform care models using the same leadership team simultaneously managing day-to-day operations; dedicated transformation capacity – potentially through a hosted ‘NewCo’ or ring-fenced delivery structure – is likely to be necessary for the most complex changes to allow teams to work across traditional organisation boundaries. Metrics must be tracked ruthlessly and reported at board and Gateway Review alongside construction milestones.
Dr Nicole Samuel
Dr Nicole Samuel is a healthcare strategist and clinician with a track record of delivering complex transformation across the NHS. Nicole is commercial director for the National Centre for Child Health Technology at Sheffield Children’s NHS Foundation Trust, working in partnership with the NIHR HRC in Paediatrics and Child Health to accelerate market access and deployment of child health technology. With over a decade of experience spanning clinical practice, academia, industry, and consultancy – including direct involvement in new hospital builds and system transformation programmes – she brings a combination of clinical insight and commercial expertise to the challenge of improving health at scale.
4. Build long-term resilience into governance. Governance structures must provide clear accountability for transformation outcomes, explicit escalation routes when trajectory drifts, and a culture of learning and continuous improvement. System- wide change – particularly the shift of services into community settings that underpins many NHP business cases – requires governance that extends beyond the acute Trust to encompass the full ICB system.
For estates managers and capital programme leaders specifically, there is an additional and practical implication. The design and configuration of new facilities already encode assumptions about how care will be delivered: the number of beds, the layout of wards, the design of emergency departments, and the location and sizing of clinical adjacencies. These design decisions are
downstream consequences of clinical and operational models. When those models are not yet defined, or when there is insufficient confidence that the workforce and system can deliver them, the building itself may be fundamentally misconfigured for the operational reality it will face. Estates professionals need to convene system partners
around the build programme – coproducing a funded transformation programme that transforms services in line with the design assumptions. Research suggests the impacts on local people, the workforce, and the health and care system can be huge if they do not.
Conclusion: assuring both transformation and capital build The NHS is embarking on the most significant programme of capital investment in a generation. The New Hospital Programme represents an extraordinary opportunity to modernise infrastructure that in some cases has been unfit for purpose for decades. But the research is unambiguous in its conclusion: new buildings do not, on their own, deliver better care. They create the conditions in which better care becomes possible. Realising that possibility requires the same discipline, resourcing, and assurance that we apply to the construction itself. One NHS chief executive, quoted in the research, put it plainly: “Current capital and operating costs are likely to be unaffordable in every NHP trust and system.” That is not a counsel of despair – it is a statement of the scale of the challenge, and a call to take it seriously. The organisations that will open their new hospitals successfully are those that treat transformation not as an add-on to the capital programme, but as its most important deliverable. The risk of not transforming is not theoretical. The cases
At the heart of the problem is the ‘transformation gap’: the distance between what a new build is designed to achieve and what people and technology are actually ready to deliver on opening day. This gap is baked into the economics of hospital building itself.
60 Health Estate Journal August 2026
of Royal Adelaide and Royal Liverpool demonstrate, in human and financial terms, what that risk looks like when it materialises. Midland Metropolitan demonstrates that a different outcome is achievable with the right investment, the right leadership, and the right commitment to making transformation the true measure of success.
References 1
News.com.au, Billion dollar bungles at the Royal Adelaide Hospital, Australia’s most expensive building, puts ‘lives at risk’, 2018.
2 BBC, Royal Liverpool Hospital: New A&E overcrowded and chaotic, medics say, 2023.
Further reading n Rose S, Samuel N. Embedding Transformation in Healthcare
Capital Programmes: Lessons from Leading Approaches. European Healthcare Design Congress; 2025.
n IMPOWER Consulting. Roundtable Briefing: Embedding Transformation in NHP Programmes. October 2025.
n The Health Foundation. Demand for health and social care: projections to 2032–33. 2023.
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