INFRASTRUCTURE
Balancing act: Operations amidst project delivery
Sujiv Fonseka and Vakhtang Takov, of Turner & Townsend, a global consultancy specialising in programme and project management, explore the challenges of delivering major capital projects within live NHS hospital environments. Drawing on decades of healthcare project management experience, they highlight how careful planning, stakeholder engagement, and operational resilience are essential to modernising facilities while maintaining continuity of patient care and service performance.
The NHS estate is one of the largest and most complex public sector property portfolios in Europe, comprising over 24,000 assets across more than 1,200 sites. Many of these facilities are ageing, with 15 per cent of buildings in England constructed before the NHS was founded in 1948. The estate now has a critical maintenance backlog
that is estimated to have reached £13.8 bn in 2023/24 – a figure that has more than doubled in real terms since 2015/16. Of this total, 55% is classified as critical infrastructure risk, meaning failure could result in catastrophic disruption to clinical services. In the same year, over 1,500 critical incidents were reported, with clinical time lost due to infrastructure issues exceeding 600 days. Examples include cancelled surgeries due to electrical faults, chiller failures in operating theatres, and fires caused by water ingress into essential power systems. The government has allocated over £1 bn to address
the most urgent maintenance needs; and efficient execution requires a strategic approach to ensure the delivery models, and controls, are structured to meet the complexity of the challenge, and ensure best value for the individual Trust and the NHS. Modernising the estate and building resilient, future-proofed facilities is essential not only for patient safety but also for meeting NHS performance targets and sustainability goals. These critical and urgent projects are often executed as part of a Trust’s annual capital plan on short turnaround times alongside other, larger developments that may be taking place at the Trust’s site, including new buildings and large-scale refurbishments. These larger developments must consider the impact and alterations they impose upon the operational environment of the live hospital site.
Delivering in a live environment: A complex balancing act The implementation of large-scale projects affects core operational functions, including goods delivery, waste management, smaller capital projects, and other estates services, all of which are critical to maintaining clinical performance and patient care. Temporary access restrictions, site reconfigurations, and increased contractor presence can create logistical bottlenecks, raise operational risks, and reduce flexibility for routine services. Proactive planning, phased delivery strategies, and early stakeholder engagement are essential to mitigating these impacts. Managing business-as-usual alongside project delivery also carries hidden costs, making it crucial to involve facilities management teams from the earliest design stages to ensure continuity and service resilience.
By aligning capital project goals with operational realities, Trusts can safeguard patient experience and service quality during periods of transformation. Delivering major healthcare infrastructure projects
within operational hospital environments is one of the most complex challenges facing NHS Trusts today. As the demand for modern, efficient and sustainable facilities grows, so too does the pressure to maintain uninterrupted, high-quality patient care during construction. This dual imperative, generating progress whilst maintaining continuity, requires a carefully orchestrated approach and a delivery structure that recognises and places operational resilience at the heart of capital project planning and delivery.
Protecting the core: Managing the impact on business-as-usual When a Trust initiates the development of new acute facilities on an existing hospital site, one of the earliest and most pressing concerns is the potential disruption to the logistics network that underpins the hospital’s daily operations. These networks are the invisible lifelines of hospital functionality. Goods deliveries, catering supplies, medical consumables and linen arrive daily via tightly scheduled routes, often through constrained service yards located adjacent to busy urban roads – particularly for Trusts based in central London whose estates, over time, have seen expansion and densification that have stretched internal delivery routes to their maximum physical capacity.
October 2025 Health Estate Journal 175
Failure to address the £13.8 bn maintenance backlog could lead to catastrophic disruption to clinical services.
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