Renewing Our Hospitals

The UK’s hospital estate is large, ageing and expensive to run. Recent government moves – including the creation of the National Infrastructure and Service Transformation Authority (NISTA) and a refreshed New Hospital Programme – aim to bring order to
a decade of under-investment. But delivering a programme of major rebuilds, upgrades and targeted retrofits across hundreds of sites is as much a people and governance problem as it is a money and planning problem.

This article explores who will own NHS building projects, why leadership and capability are central risks, and strategic considerations to close the gaps.

Where responsibility sits: the current landscape

Local NHS organisations (Trusts) and Integrated Care Boards (ICBs) remain the natural owners of local estate decisions and are responsible for strategic capital planning including options for refurbishing or replacing buildings. The Fit for the Future 10 year Health Plan for England (July 2025) introduced a new NHS operating model, with a focus on devolution of
power and decision-making. The stated aim being that every NHS provider should be an FT with freedoms including the ability to retain surpluses and reinvest them and borrowing for capital investment by 2035.
National programmes and major hospital schemes are being run at national level. The Government’s recent announcement commits to delivering the New Hospital Programme and describes central oversight, funding envelopes, and a national implementation plan. The programme has assigned national delivery leadership (for example the New Hospital Programme’s Chief Programme Officer) to coordinate delivery and to work with local organisations.
NISTA’s role is as a new national centre of strategic expertise and project assurance. Formed in 2025 from a merger of previous bodies, NISTA sits inside government (Treasury/Cabinet Office remit) and brings together strategic planning, project finance and assurance capability to advise ministers and support major projects across sectors, including hospitals. NISTA will not replace local ownership, but it will influence go/no-go decisions, standards, and assurance of major schemes.

In short: ownership is layered. Local trusts and ICBs are the day-today owners and developers of business cases and estates strategy; national bodies (DHSC, NHS England and national programmes such as the New Hospital Programme, with assurance and advisory input from NISTA) provide funding decisions, programme management support, and final approvals for the largest schemes.

The capability gap:

As autonomy increases, leaders are increasingly aware of the potential risks to delivery:

Complex programme management is a specialist skill. Delivering a multi-site, multi-wave hospital programme requires end-to-end capabilities: strategic business case development, options appraisal (new build vs upgrade), procurement and commercial structuring, cost and schedule control, clinical and operational change leadership, risk and stakeholder management, and post occupancy evaluation. The 2023 National Audit Office Report on the New Hospital Programme identified the lack of mature project delivery teams at this scale, particularly in smaller or financially stretched trusts, as a potential
inhibitor of successful delivery.
Fragmented governance and funding constraints. The 2023 NAO report also highlighted that capital allocation splits between system-level allocations and nationally allocated funds means accountability can be unclear: who funds the feasibility work? Who underwrites cost overruns? The NAO and sector bodies have repeatedly flagged that the capital regime and approval pathways slow projects and leave local leaders having to reallocate scarce resources to progress the early design work. Whilst
the Fit for the Future 10 Year Health Plan for England health plan should simplify this in the long term, in the short term there may be increased uncertainty.

Backlog and urgency drive short-termism. Esme Kirk-Wade, in her review published in February 2024, notes that the maintenance backlog in the NHS estate has more than doubled from £5BN to £11BN to the end of 2023, with investment amounting to only 12% of this cost. 54% of backlog in 2024 was considered high or significant risk. This necessarily leads to quick fixes and emergency works, which compete for capability and management focus with the longer-term programme development needed to make good rebuild-or-refurbish decisions. House of Commons Library, The Guardian

Business case and options appraisal capability. Deciding whether to upgrade an existing facility or build new is fundamentally an options appraisal and whole-life-cost decision. Producing a robust, comparable appraisal across many sites is resource-intensive and requires experienced capital-planning leadership.

Who will run day-to-day programmes and will they have the skills?

Day-to-day programme owners: For most hospital upgrades and smaller schemes, the trust (with its capital or estates team) will be the accountable owner. For schemes in the New Hospital Programme or other nationally prioritised builds, delivery will be jointly managed between local trusts and national programme teams (DHSC / NHS England), with national programme directors providing leadership and, in many cases, direct delivery support. NISTA will provide strategic
assurance and advice for major decisions and go/no-go points.

Do they have the skills? The short answer: not consistently. Where trusts or ICBs have well-resourced estates and programme management offices (PMOs), they can run complex projects competently. But many trusts lack the depth, and the sector overall has a documented shortage of senior programme directors, commercial specialists and cost/schedule controllers required for dozens of simultaneous major projects, exacerbated by broader high demand for skill project and programme management talent in both public and private sectors of the UK market.

What this means for the “build vs upgrade” decision

A robust decision between upgrading and rebuilding depends on three things:

• High-quality option appraisals and whole-life costing: comparing capital, operating, clinical outcomes, decanting requirements and carbon/sustainability impacts. These require experienced estates analysts and capital planners.
• Clear funding and risk allocation: who pays for the preferred option, and who bears overruns? Clarity on funding enables better long-term decisions.
• Capacity to deliver: even best decisions are at risk if there aren’t programme directors, procurement teams, and delivery chains in place to manage complex construction and transition while clinical services continue. National Audit Office (NAO).

Given current capability gaps, many local organisations will need nationally provided assessment tools, standards and direct delivery support to make and implement robust build/upgrade decisions at scale.

Conclusion

The architecture is emerging. Local trusts and ICBs will continue to be the legal and operational owners of most estate projects, national programmes and DHSC/NHS England will fund and coordinate the largest schemes, and NISTA will act as the strategic assurance and transformation authority. Early option appraisal work and clarity on funding and clarity will be vital. But the key to successful delivery is to rapidly scale delivery capability. The questions to consider include:

Should early-stage capability and feasibility work be centralised? Would national centres (NISTA, NHS national programme teams) to provide standardised option appraisal tools, standard business-case templates and funded early design work better enable local owners to make comparable, evidence-based decisions?

Should there be a national delivery surge capacity (programme directors & PMOs)? NAO and sector papers
support a stronger central delivery spine. Is there value in developing experienced delivery leads into regional hubs or into national programme teams for wave-based delivery, rather than relying solely on local capacity?

How to best invest in workforce development for estates and programme management? Upskill trust and ICB
estates teams with accredited project and commercial training whilst creating fast-track recruitment for senior programme roles?

How can the sector compete in the war for programme and project talent? With programme and project management skills predicted to be increasingly in demand, and other sectors more able to compete on price, should attraction strategies focus on purpose?