ESTATE MAINTENANCE
6 5 4 3 2 1 0
Year
2024 2025
Low
Graph showing cost to eradicate NHS backlog by risk level 2024-2025.
Moderate Significant Backlog risk level
Measurable improvements This is not a theoretical exercise. Structured approaches to backlog and risk analysis have already supported measurable improvements in estate risk management. This enables Trust Boards to be presented with clearer information and a more transparent picture of the risks and their potential disruption to clinical services. In practice, we have observed measurable reductions in risk within a single year, even with the constraints of an operational NHS environment, including working around clinical areas, procurement compliance, and delays in funding approvals. Ongoing data iterations, which incorporate new priorities, updated risks, and budget adjustments, allow for programme reviews and further risk reduction forecasts in the upcoming years. Multiple scenario analysis supports estates teams in presenting technical data and estate risks in a way that aligns with the wider hospital strategy, improving understanding and support from decision makers. We have seen in several cases working with NHS
Trusts, the use of data-led prioritisation and planning has allowed for a greater amount of risk reduction per pound spent as well as an ability to plan much longer term.
Andy Vernon
Andy Vernon is sector director of Healthcare at Hoare Lea, with decades of experience delivering engineering, design, and advisory services across the health sector. He has been involved in approximately £2bn of healthcare projects, spanning major new build and complex remodelling programmes. Andy leads healthcare activity across the practice, ensuring best practice is embedded and shared. As MEP lead for NHS England frameworks, he has driven standardisation and repeatable design solutions, delivering significant cost savings and improved outcomes for the NHS.
Sustainability and Net Zero The NHS has committed to reaching zero carbon emissions by 20405
for its directly controlled emissions (2045 for
its wider supply chain), placing increasing sustainability expectations on Trust estates and capital planning. Some Trusts have set more ambitious targets to achieve
Net Zero ahead of national timelines. While sustainability plans can be developed to achieve these ambitions, in many Trusts the condition of the estate and the scale of maintenance backlog forces teams to prioritise immediate operational risks, limiting the ability to focus on sustainability targets. Addressing backlog maintenance first does not conflict with sustainability objectives. As well as reducing risks, it can improve energy efficiency, reduce maintenance costs, and contribute to carbon reduction. As backlog projects are completed, the associated sustainability improvements can be quantified, providing a clearer understanding of the wider value of investment to board level decision makers. This is directly correlated using years of ERIC data to analyse the carbon performance of Trusts relative to the amount of backlog maintenance prevalent within an estate. Conclusively, there is a direct connection between poor maintenance condition and lower carbon performance.
Morale and wellbeing The effect of an estate that is not fit for purpose has on care outcomes and staff wellbeing both for clinical and estates staff can be significant. Correlating can be difficult to confirm as processes and systems for risk reporting and management have created separation between the impact of backlog maintenance and the clinical impact. However, a 2022 report from the British
72 Health Estate Journal September 2026 High
Medical Association (BMA) found that 43 per cent of doctors believed poor workplace conditions were negatively affecting patient care, while 38 per cent rated their facilities as poor or very poor. Furthermore, the effect of backlog maintenance on revenue generation through downtime for key healthcare services is an area that needs further dedicated research and quantification. The financial implications of backlog maintenance extend far beyond repair costs. Every time an operating theatre or ward is closed due to infrastructure failures, trusts lose thousands of pounds in revenue and valuable staff time. In addition, hospital bed closures, caused by estate issues, exacerbate system- wide pressures, resulting in delays in-patient admissions and ambulance handovers. In addition, the impact of the estate conditions on staff wellbeing and morale is increasingly recognised as moral injury which has significant detrimental effects on staff turnover. Beyond morale, operational disruptions caused by infrastructure failures – such as ward closures – result in cancelled procedures, contributing to longer waiting lists and delayed care. These disruptions ripple through the system, causing inefficiencies and increasing patient wait times.
A structured, unbiased approach Although estates risks are well known to estates teams, day to day operational pressures, alongside fragmented and incomplete data, can make it difficult to translate known issues into deliverable estates programmes. Multiple organisational and assurance layers, as well as limited representation of estates at board level, can dilute the urgency of risks and their potential effects on clinical areas and patient care outcomes. As a result, estate investment budgets are reduced, limiting estates teams’ ability to act, contributing to a vicious cycle of increasing backlog, rising risks, and increased operational pressures. Despite the Government’s NHP programme announcement, a significant number of Trusts will continue to manage ageing estates and increasing backlog problems. Procurement constraints, insufficient funding, and the pressure to maintain clinical operations, often result in small scope solutions, designed to mitigate immediate risks. In the long term, these solutions increase risks and energy costs and create further strain on hospital infrastructure capabilities and team resources. A more structured approach is required. We have found
that, by analysing existing data, however incomplete, and translating it into a clear, risk-led, deliverable programme of works, this can support estates teams in presenting evidence-based investment plans to the Boards. This enables a clearer understanding of risks, their potential to disrupt clinical services, and the implications of different investment scenarios over time. A structured, unbiased approach to backlog and risk
analysis can enable Trusts to develop and deliver multi-year programmes, focused on risk reduction while balancing impacts on clinical areas – supporting sustainability objectives and improving staff wellbeing.
References 1 The Health Foundation. The NHS maintenance backlog: rising costs and falling investment. 2024
2 Serle J. Estates and facilities management in the NHS: 2026 update. Health Service Journal. 23 Apr 2026
3 Ellis C. Smaller, leaner estate: making it happen. Health Estate. 2012; 66(9):29–33
4 NHS England. A risk-based methodology for establishing and managing backlog. 2004
5 NHS England. Delivering a Net Zero National Health Service. 2020
Cost to eradicate (£bn)
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