Building the future: healthcare infrastructure reports

Estates infrastructure

Updated: Monday 5 December 2022

The report examines the alarming condition of the UK’s healthcare estate, shining a new light on its impact on doctors and the patients they care for.

Using the findings of a BMA member survey and powerful testimony from frontline doctors, the report also makes a powerful argument for urgent investment in the bricks and mortar of our health systems.


Maintenance and modernisation

Healthcare estates are in urgent need of maintenance and modernisation

The quality of healthcare estates has a direct impact on the health, safety, and wellbeing of staff and patients. Healthcare facilities in poor condition present greater risk to staff and patient safety and both create and exacerbate negative working conditions.

In addition, the COVID-19 pandemic has shown the importance of buildings that can accommodate adequate IPC (infection prevention and control), with enough space for social distancing and proper ventilation systems.

Besides maintenance and IPC, digital transformation and modernisation are also essential to the delivery of effective, safe, and modern healthcare, as explored in the other report in this series, Getting IT Right: A Prescription for Safe, Modern Healthcare.



Perhaps the most widely reported and most-visible consequence of underinvestment in healthcare estates are spiralling hospital maintenance backlogs, which show extent of investment needed to ensure all hospitals meet even the most basic standards.



Key recommendations

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  • All UK governments must launch transparent and independently audited national reviews of the condition of the primary and secondary care healthcare estates in England, Northern Ireland, Scotland, and Wales, building on existing work where appropriate.
  • As part of the independently verified audit of their healthcare estate, all UK governments and health systems must carry out an urgent review of IPC and ventilation across the primary and secondary healthcare estate, with dedicated funding for improvements and retrofitting.
  • All UK governments and health services must link their IT and digital transformation programmes with the wider development and enhancement of their healthcare estate, to ensure that hospitals and GP practices are capable of supporting new technology and IT systems.
  • Funding must be provided to allow hospitals and GP practices to upgrade or retrofit their premises to allow for new technology to be fitted or better accommodated.
  • All buildings should have adequate Wi-Fi accessibility and high-speed broadband connections, those without should receive urgent support to make the necessary improvements. Future new builds or refurbishments should be designed with these factors in mind as well as the need to allow for future connection methods to be installed.
  • UK governments should provide the necessary funding to urgently clear existing maintenance backlogs – or decide to rebuild sites that may no longer be appropriate to repair – in order to protect doctors and patients, and to prevent any further growth in the already enormous list of outstanding and costly remedial repairs.
  • All UK governments must be fully transparent regarding maintenance backlogs within the publicly-owned healthcare estate, publishing these figures at least annually.

Capacity, safety, and wellbeing

Healthcare environments must be designed with capacity, safety, and wellbeing in mind

It is vital for both staff and patients that healthcare environments are spacious, well-designed, and fit for purpose. There must be sufficient space for doctors to rest and do their job. The provision of sufficient rest areas, office spaces, and clinical areas are vital to both the wellbeing of doctors and their ability to deliver the best possible care to patients.

Of equal importance to increasing the amount of space available is ensuring that buildings we do have are properly configured and used to their full potential. Well-designed buildings with an intuitive layout improve efficiency and staff wellbeing, which in turn improves patient care. Closely involving doctors in estates planning can help ensure that healthcare environments are intuitive, efficient, and safe.

Finally, it is vital that hospitals and GP practices, as well as transport links to them, are accessible to staff and patients with disabilities or mobility needs.


Key recommendations

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  • All providers should ensure break spaces are made available in the short-term, and that all new buildings and expansions include guaranteed break spaces compliant with guidelines set out in the BMA Fatigue and Facilities Charter and Junior Doctor Wellbeing checklist, and designed with the direct input of doctors.
  • National reviews of healthcare estates should include an assessment of dedicated staff break space in all UK hospitals by the relevant healthcare services, building on best practice and the input of doctors and NHS staff. Health services and providers should then work directly with trade unions to design and implement improvements to break space.
  • All doctors must have access to quiet, comfortable office spaces where they can work without interruption, and discuss confidential matters in private.
  • In the medium term, more space must be created through the expansion of existing premises and where required through newbuilds. This requires substantial capital investment so that more funding can be made available to hospitals and GP practices, as well as other healthcare premises.
  • Any nationally mandated increase in primary care staffing within GP practices must be accompanied by additional funding for premises expansions and improvements, in order to properly accommodate additional staff.
  • Funding should be made available to GP practices and hospitals to make necessary accessibility improvements where possible or – where not – to ensure new premises are fully accessible as standard.
  • All healthcare providers must carry out an assessment of their accessibility by transport and the transport options available for staff and patients.
  • All healthcare providers should work on improving their sites’ accessibility, including by improving cycle storage, working with public transport providers to improve access, improving car parking facilities and offering free parking to staff and patients.


The condition of the healthcare estate has an impact on the climate and the environment

Healthcare organisations are major contributors to carbon emissions and need increased support by UK Governments to achieve sustainability goals, as previously recommended by the BMA.

This support should include increased capital investment to make healthcare buildings more energy-efficient – via improving insulation, modernising heating systems, and switching to renewable energy sources and more sustainable modes of transport.



Key recommendations

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  • UK governments must better support healthcare organisations to meet their carbon reduction targets; this support must include ringfenced capital funding for improvements to improve the sustainability of all health service estates across the UK.
  • All UK healthcare systems should explore options for the provision of interest free ‘sustainability loans’ to GP practices to facilitate improvements to their premises. This should be developed with the input of GPs and practice staff, to ensure these loans are accessible and easy to draw down.
  • All healthcare systems and local structures – such as Health Boards and ICSs (Integrated Care Systems) – should review the sustainability of transportation options to their estates and aim to boost sustainable transport options further in any environmental or transport plans produced.
  • All healthcare providers should take steps to future-proof their estate for sustainable and developing transportation options, including the provision of sufficient EV charging points.

Capital funding and investment

Steeper increases in capital funding are needed

The decay of many hospital buildings and GP practices across the UK is ultimately due to insufficient capital spending.

Though it is normal for capital spending to fluctuate, capital investment in the UK has been consistently low over the last two decades compared to historic capital spend, other health spending, and international capital spend.

If healthcare systems are to meet their performance targets and tackle waiting lists, capital investment into the estate has to increase, and application processes for capital investment must be improved.



Key recommendations

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  • Higher levels of capital funding must be provided in order to address long-term underinvestment and its impact on healthcare estates.
  • UK governments must ensure that previous mistakes are not repeated, by protecting capital spending budgets so they cannot be not offset to prioritise other areas.
  • UK governments should have a long-term capital investment strategy to ensure capital spending is allocated to key areas of priority, including ringfenced budgets to address maintenance backlogs and a clear plan of how and when maintenance backlogs will be resolved.
  • Ensure application and decision processes for capital funding (in primary and in secondary care) are clear and transparent, and reduce bureaucracy to a minimum.


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