An Essay on How the Built Environment Should Support Clinical Service, Not Be a Cash Cow to Raid

Introduction

Healthcare estates and facilities—hospitals, clinics, community health centres, and all associated infrastructure—form the physical backbone of any healthcare system. They house the services, technologies, and professionals that are critical to patient care. Yet in recent years, the purpose and management of these estates have often diverged from their primary function. Instead of being viewed as enablers of clinical excellence, healthcare facilities are increasingly being seen as financial assets—real estate holdings to be monetised or downsized under fiscal pressures. This paper explores the systemic problems with the current approach to healthcare estates and argues for a refocusing on how the built environment can and must support clinical service delivery, not merely serve as a convenient source of revenue or cost-cutting.

The Current Crisis in Healthcare Estates

One of the most pressing issues facing healthcare estates today is chronic underinvestment. Many hospitals in the UK, and other healthcare systems are functioning in facilities that are outdated, poorly maintained, and no longer fit for purpose. The backlog of essential maintenance in NHS buildings, for instance, has reached billions of pounds. Leaky roofs, crumbling infrastructure, and outmoded layouts make it increasingly difficult to deliver safe, effective, and modern healthcare.

Alongside this decay is the financial strategy that treats estate rationalisation as a means of balancing the books. Governments and health systems have increasingly looked to their property portfolios to plug budget gaps—selling off valuable land or buildings, closing underused facilities, and outsourcing maintenance. While this may generate short-term gains, it often leads to long-term problems. Once a facility is sold, the system loses flexibility, space, and capacity—assets that become critical in times of crisis, such as pandemics.

Moreover, Private Finance Initiatives (PFIs) and similar funding models have exacerbated the problem. Many healthcare systems now find themselves locked into long-term contracts with private providers for building maintenance, which are often poor value for money and limit the ability of managers to adapt facilities to clinical needs.

Facilities Should Follow Function: The Role of the Built Environment in Clinical Care

The built environment in healthcare is not just a backdrop—it directly impacts outcomes. Numerous studies have shown that design choices in hospitals—such as natural lighting, noise levels, spatial layouts, and accessibility—can affect rates of infection, patient recovery times, and staff morale. When estates are driven by financial considerations rather than clinical logic, these benefits are often lost.

A core principle that should guide healthcare estate planning is “form follows function.” In other words, the architecture and layout of healthcare facilities must be aligned with how clinical care is delivered. This includes:

• Integrated care models that bring together primary, secondary, mental health, and social care under one roof.

• Flexible designs that can be easily adapted as services evolve or patient needs change.

• Patient-centered environments that reduce stress, improve wayfinding, and respect privacy and dignity.

• Staff-focused spaces that promote efficiency, collaboration, and well-being.

  
  

However, these goals are rarely prioritised when estates are treated as financial assets first and clinical tools second. Decisions about closing, merging, or selling facilities are often made without sufficient input from clinicians, estates professionals, or patients, leading to disjointed service delivery and worsening access to care.

A Vision for Clinically Led Estates Planning

To realign the built environment with healthcare delivery, there must be a radical shift in governance, strategy, and investment.

First, estate planning must be user led. The voices of healthcare and estates professionals, patients, and local communities should guide decisions about where facilities are located, what services they provide, and how they are designed. Strategic estate planning should not be a finance-driven exercise, but a collaborative process supporting long-term population health.

Second, public investment is critical. Governments must stop treating healthcare estates as liabilities and start recognising them as critical infrastructure, no different from schools or transportation networks. Investment in well-designed, modern, and flexible facilities – whether refurbishing existing or building new - should be seen as a core part of improving healthcare outcomes and resilience.

Third, sustainability and resilience must become central to estate strategies. Climate change, pandemics, and evolving technology demand that healthcare infrastructure be robust, green, and future-ready. Facilities that are energy-efficient, digitally integrated, and adaptable to emergencies are no longer a luxury—they are a necessity.

Finally, data and innovation should inform estates planning. Leveraging data on patient flows, demographics, and service usage can ensure that the built environment is responsive and efficient. Smart buildings, AI-powered maintenance systems, and telehealth-enabled layouts are already showing promise in improving both care and operational efficiency.

Conclusion

The healthcare estate is not just a balance sheet item—it is a clinical asset that can enhance or hinder the delivery of care. Treating healthcare facilities as mere financial instruments undermines the core mission of healthcare: to heal, support, and serve. A new approach is urgently needed, one that puts clinical service at the heart of estate management and design. With thoughtful planning, adequate investment, and a commitment to supporting patient care through infrastructure, the built environment can fulfill its true potential—not as a cash cow to raid, but as a pillar of modern, compassionate, and effective healthcare.