In the opening keynote address at Healthcare Estates 2026, three speakers addressed the question of whether the NHS is heading for a two-tier estate and if so, what can be done about it.
There is certainly the potential for that to be the case, given the high profile status of the New Hospital Programme, but the speakers shared plenty of insight around strategies to prevent this happening, emphasising that existing estate should not be allowed to become a secondary priority; the patient should be able to expect the same high quality of care regardless of the age of the hospital buildings.
The growing level of backlog maintenance (predicted to exceed £18bn in this year’s ERIC figures) and increasing incidents where an estates failure has led to disrupted patient services indicates how critical it is that the NHS does not lose sight of its existing, often aged estate.
Repositioning the estate
David Jones, Director of Estates, Facilities & Capital Development at University Hospitals Southampton NHS Foundation Trust, who has studied backlog maintenance and strategies to manage it as part of his PhD, agreed that yes, the NHS is heading for a two-tier estate, but he added that why is the more complex question.
David was quite clear in his message that risks of estate failure need to be repositioned as risks to patient safety, and they need to be recognised before the risk turns into a hazard and results in patient harm. “Stop managing backlog as a maintenance problem. Start managing it as patient risk,” he said.
This is one element to a series of solutions that David put forward to break the cycle of backlog maintenance and estate risks becoming part of ‘business as usual’. Others include establishing clear ownership of estates problems so that clinical staff too report issues that they see, moving from condition-based to risk-based maintenance, introducing infrastructure safety surveillance systems, integrating estates data into patient safety systems and transitioning from reactive to preventive investment.
Making better use of existing estate
Dr Shamir Ghumra, Executive Director of Responsible Business at NHS Property Services argued that a two-tier estate isn’t inevitable. “What we do is defined by how intelligently we use the estate,” he said.
The NHS has a huge estate, but the challenge it faces is bigger than new builds alone; the challenge is making existing estate more useful, and ensuring every square metre of space works harder. However, recent research has found that nearly nine in ten leaders have only a low to medium awareness of how their space is used and more than half lack the data to make optimal estate decisions.
Estate backlog continues to outpace investment, but Shamir argued that maintenance is one of the most powerful tools we have for preventing a two-tier estate and that it should be viewed as an enabling tool for improving productivity, patient flow, sustainability, clinical resilience and workforce experience.
Challenge
Simon Corben, Director and Head of Profession, NHS Estates, NHS England, challenged the assertion, saying “maybe, but why don’t we do something about it?” Simon pointed out that the NHS capital spend is more than it has been for a very long time and only around 20% of that is part of the New Hospital Programme. It’s critical that this capital is used to improve the estate and reduce risk. The opportunity presented by the capital, together with other issues, such as the rapid advancement in digital tools which are getting better every day is significant, but the system needs to improve capital planning to reduce backlog and risk, increase productivity and achieve the shift to neighbourhood healthcare.
Simon also issued a plea for improved incident tracking asking everyone to report any occasions where an estate failure has stopped clinical activity. He used the example of the extreme hot weather during summer causing the closure of operating theatres, very few of which have been reported. Estates failures resulting in disruption to clinical services remains one of the most powerful tools there is for making the case to the Treasury for more capital investment.
